Neck injuries in young pediatric homicide victims

Acute presentation of abusive head trauma

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.

My Journey

This is the life story of Dr. Lucy B. Rorke-Adams, who was raised in the rural Midwest of the United States by Armenian immigrant parents during the Depression. The youngest in a family of five girls, she was lovingly nurtured by her parents and sisters. She was encouraged to become educated in order to lead a worthwhile life and contribute to society. She chose medicine, specifically the specialty of pediatric neuropathology, and over her long career succeeded in advancing the field. In particular, she made major contributions to understanding childhood brain tumors, central nervous system (CNS) malformations, and pathophysiology of abusive CNS injury in infants and children.

A Biomechanical Assessment of Shaken Baby Syndrome: What About the Spine?

BACKGROUND

Shaken baby syndrome occurs following inertial loading of the pediatric head, resulting in retinal hemorrhaging, subdural hematoma, and encephalopathy. However, the anatomically vulnerable cervical spine receives little attention. Automotive safety literature is replete with biomechanical data involving forward-facing pediatric surrogates in frontal collisions, an environment analogous to shaking. Publicly available data involving child occupants were utilized to study pediatric neck and head injury potential. We hypothesized that inertial loading provides a greater risk of injury to the cervical spine than to the head.

METHODS

Full-scale automotive crash tests (n = 131) and deceleration sled tests (n = 32) utilizing forward-facing 3-year-old surrogates with head accelerometers and cervical force sensors were analyzed. One hundred sixty-seven full-scale vehicle and 33 sled test runs were assessed in the context of published injury assessment reference values (IARVs) for closed head injury (head injury criterion 15 [HIC₁₅]) and cervical tensile strength in the 3-year-old model.

RESULTS

One hundred sixty-one (96%) child surrogates in full-scale crash tests exceeded the cervical peak tension IARV, while only 37 (22%) surpassed the HIC₁₅ IARV. Similarly, in sled testing runs, 27 (82%) pediatric surrogates exceeded cervical tension IARVs, while 1 (3%) surpassed the HIC₁₅ IARV. In both full-scale and sled tests, all surrogates surpassing the HIC₁₅ IARV also exceeded the cervical tension IARV. Positive linear correlations were observed between HIC₁₅ and cervical tensile forces in both full-scale vehicle (R² = 0.15) and sled testing runs (R² = 0.54).

CONCLUSIONS

These data support the hypothesis that inertial loading of the head provides a greater injury risk to the cervical spine than to closed-head injury.

Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT)

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological "triad", a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216-223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44-48% when all the spinal cord levels are analysed as opposed to just 0-18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma

In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration-deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.

Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury

OBJECTIVES

The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).

METHODS

We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.

RESULTS

Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.

CONCLUSIONS

Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.

Consensus statement on abusive head trauma in infants and young children

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.

Evaluation of Two Models of Non-Penetrating Captive Bolt Devices for On-Farm Euthanasia of Turkeys

Simple Summary

Animal care guidelines for livestock and poultry require farms to have euthanasia plans in place for birds that are sick, injured, or unable to access feed and water. Killing methods considered to be humane are those that induce rapid insensibility (stun) and result in brain death leading to irreversible respiratory and cardiac arrest. Therefore, the evaluation of the effectiveness of a killing method generally focuses on measures of insensibility and brain death. Non-penetrating captive bolt devices are intended to deliver sufficient force and energy to the head to result in immediate insensibility and brain death without penetrating the skin. We evaluated the effectiveness of two models of non-penetrating captive bolt devices when applied by stock people to different sizes and ages of turkeys, using signs of insensibility corroborated by ante- and post- mortem evaluation of brain damage. Both non-penetrating captive bolt devices used in this study were found to be highly effective at inducing immediate insensibility and would be appropriate for on-farm euthanasia of turkeys of various ages and size.

Abstract

On-farm euthanasia is a critical welfare issue in the poultry industry and can be particularly difficult to perform on mature turkeys due to their size. We evaluated the efficacy of two commercially available non-penetrating captive bolt devices, the Zephyr-EXL and the Turkey Euthanasia Device (TED), on 253 turkeys at three stages of production: 4–5, 10, and 15–20 weeks of age. Effectiveness of each device was measured using both ante- and post-mortem measures. Application of the Zephyr-EXL resulted in a greater success rate (immediate abolishment of brainstem reflexes) compared to the TED (97.6% vs. 89.3%, p = 0.0145). Times to last movement (p = 0.102) and cardiac arrest (p = 0.164) did not differ between devices. Ante- and post-mortem measures of trauma and hemorrhage were highly correlated. Skull fractures and gross subdural hemorrhage (SDH) were present in 100% of birds euthanized with both the Zephyr-EXL and TED devices. Gross SDH scores were greater in birds killed with the Zephyr-EXL than the TED (p < 0.001). Microscopic SDH scores indicated moderate to severe hemorrhage in 92% of turkeys for the Zephyr-EXL and 96% of turkeys for the TED, with no difference between devices (p = 0.844). Overall, both devices were highly effective inducing immediate insensibility through traumatic brain injury and are reliable, single-step methods for on-farm euthanasia of turkeys.

Cervical spine injuries in young children: pattern and outcomes in accidental versus inflicted trauma

BACKGROUND

The aim of the study was to compare the cervical spine (c-spine) pattern of injury and outcomes in children below 3 y with a head injury from confirmed inflicted versus accidental trauma.

METHODS

After Institutional Review Board approval, data were prospectively collected between July 2011 and January 2016. Inclusion criteria were age below 3 y, a loss of consciousness, and any one of the following initial head computed tomography (CT) findings (subdural hematoma, intraventricular, intraparenchymal, subarachnoid hemorrhage, or cerebral edema). A protocol of brain and neck magnetic resonance imaging and magnetic resonance angiography was instituted. Brain and neck imaging results, clinical variables, and outcomes were recorded. Data were compared by t-test for continuous and Fisher exact test for categorical variables.

RESULTS

73 children were identified, 52 (71%) with inflicted and 21 (29%) with accidental trauma. The median age was 11 mo; (range: 1-35 mo). Ten (14%) had c-spine injuries, 7/52 (13%) inflicted, and 3/21 (14%) accidental. The mechanism was shaking for all inflicted and motor vehicle accident or pedestrian struck for accidental c-spine injuries. The inflicted group were significantly younger (P = 0.03), had higher Injury Severity Scores (P = 0.02), subdural hematomas (P = 0.03), fractures (P = 0.03), retinal hemorrhages (P = 0.02), brain infarcts (P = 0.01), and required cardiopulmonary resuscitation (P = 0.01). Seven with inflicted trauma died from brain injury (9.5%), one had atlanto-occipital dissociation. Six mortalities (86%) had no c-spine injury. Six with inflicted c-spine injuries survived with neurologic impairment, whereas three with accidental survived without disability, including one atlanto-occipital dissociation.

CONCLUSIONS

Compared to accidental trauma, young children with inflicted c-spine injuries have more multisystem trauma, long-term disability from brain injury, and an injury pattern consistent with shaking.

Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.

Biomechanical Response of the Infant Head to Shaking: An Experimental Investigation

Controversy exists regarding whether violent shaking is harmful to infants in the absence of impact. In this study, our objective was to characterize the biomechanical response of the infant head during shaking through use of an instrumented anthropomorphic test device (commonly referred to as a "crash test dummy" or surrogate) representing a human infant and having improved biofidelity. A series of tests were conducted to simulate violent shaking of an infant surrogate. The Aprica 2.5 infant surrogate represented a 5th percentile Japanese newborn. A 50th percentile Japanese adult male was recruited to shake the infant surrogate in the sagittal plane. Triaxial linear accelerometers positioned at the center of mass and apex of the head recorded accelerations during shaking. Five shaking test series, each 3-4 sec in duration, were conducted. Outcome measures derived from accelerometer recordings were examined for trends. Head/neck kinematics were characterized during shaking events; mean peak neck flexion was 1.98 radians (113 degrees) and mean peak neck extension was 2.16 radians (123 degrees). The maximum angular acceleration across all test series was 13,260 radians/sec² (during chin-to-chest contact). Peak angular velocity was 105.7 radians/sec (during chin-to-chest contact). Acceleration pulse durations ranged from 72.1 to 168.2 ms. Using an infant surrogate with improved biofidelity, we found higher angular acceleration and higher angular velocity than previously reported during infant surrogate shaking experiments. Findings highlight the importance of surrogate biofidelity when investigating shaking.

Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.

Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury

OBJECTIVE

Cervical imaging practices are poorly understood in young children with traumatic brain injury (TBI). We therefore sought to identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT) and to describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children.

METHODS

We performed a retrospective study of children younger than 2 years of age with TBI from 2009 to 2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls.

RESULTS

Of 2347 children with TBI, 18.7% were from abuse and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (odds ratio 7.10; 95% confidence interval 2.75, 18.35) and falls (odds ratio 2.25; 95% confidence interval 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3% to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < .001).

CONCLUSIONS

These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly 20-fold) and TBI from falls (over 10-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.

Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse

BACKGROUND

Previous research has described variability in medical evaluation of suspected abuse. The objective of this study was to identify, through expert consensus, required and highly recommended elements of a child abuse pediatrics (CAP) evaluation for 3 common presentations of suspected physical abuse in children aged 0 to 60 months.

METHODS

Twenty-eight CAPs recruited from 2 national organizations formed the expert panel for this modified Delphi Process. An initial survey was developed for each presentation based on demographics, history of present illness, past medical, family and social history, laboratory, radiology, and consultation elements present in at least 10% of CAP consultations collected for a larger study. CAPs ranked each element on a 9-point scale then reviewed and discussed summary results through a project blog over 3 rounds. Required and highly recommended elements were defined as elements ranked as 9 and 8, respectively, by ≥75% of experts after the final round.

RESULTS

From 96 elements in the initial surveys, experts identified 30 Required elements and 37 Highly Recommended elements for CAP evaluation of intracranial hemorrhage, 21 Required and 33 Highly Recommended elements for CAP evaluation of long bone fracture, and 18 Required and 16 Highly Recommended elements for CAP evaluation of isolated skull fracture.

CONCLUSIONS

This guideline reflects expert consensus and provides a starting point for development of child abuse assessment protocols for quality improvement or research. Additional research is required to determine whether this guideline can reduce variability and/or improve reliability in the evaluation and diagnosis of child physical abuse.

Abusive head trauma: a review of the evidence base

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.

Pediatric spinal trauma

Pediatric spinal trauma is unique. The developing pediatric spinal column and spinal cord deal with direct impact and indirect acceleration/deceleration or shear forces very different compared to adult patients. In addition children are exposed to different kind of traumas. Moreover, each age group has its unique patterns of injury. Familiarity with the normal developing spinal anatomy and kind of traumas is essential to correctly diagnose injury. Various imaging modalities can be used. Ultrasound is limited to the neonatal time period; plain radiography and computer tomography are typically used in the acute work-up and give highly detailed information about the osseous lesions. Magnetic resonance imaging is more sensitive for disco-ligamentous and spinal cord injuries. Depending on the clinical presentation and timing of trauma the various imaging modalities will be employed. In the current review article, a summary of the epidemiology and distribution of posttraumatic lesions is discussed in the context of the normal anatomical variations due to progressing development of the child.

Cervical Ganglia and Nerve Root Injury: Evidence for Respiratory Arrest as Initiating Injury in Pediatric Head Trauma

Cervical ganglia and nerve root injury with resultant paralysis of the phrenic nerve is proposed as a mechanism of injury in “shaken baby syndrome” or nonaccidental head injury of children. We report autopsy findings of a 22-month-old girl in which cervical ganglia and nerve hemorrhage was present along with the triad of encephalopathy, bilateral retinal hemorrhage, and bilateral subdural, intradural, and subarachnoid hemorrhages. Clear evidence of near immediate respiratory arrest was documented from first responder medical reports, juvenile witness statements, and perpetrator confession. The narrowing of time of injury from the anatomic findings at autopsy allowed investigative efforts to focus on a single individual and cleared several other adults with access to the child. Additional technical notes based on our experience are provided for users of cervical neck dissection. Hemorrhage in the tissues surrounding the vertebral artery raises a potential additional injury site in cases of neck injury.

Spinal injuries in abusive head trauma: patterns and recommendations

A growing body of scientific evidence suggests that there is an association between occult spinal injury and abusive head trauma (previously known as shaken baby syndrome). Consideration needs to be given to the nature of these injuries, the possible causal mechanisms and what investigations should be undertaken to delineate the full extent of spinal involvement in infants with suspected abusive head trauma. This association has the potential to influence our understanding of the biomechanics and subsequent neuropathology associated with abusive head trauma.

Imaging of spinal injury in abusive head trauma: a retrospective study

BACKGROUND

Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT.

OBJECTIVE

The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48 months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions.

MATERIALS AND METHODS

This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P < 0.05 considered statistically significant.

RESULTS

Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia.

CONCLUSION

Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.

Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma

BACKGROUND

In the evaluation of children younger than 3 years with intracranial hemorrhage it can be difficult to determine whether the cause of hemorrhage was traumatic, and if so, whether abusive head trauma (AHT) is a possibility. Cervical spine MRI is not a routine part of the nationally recommended imaging workup for children with suspected abusive head trauma. There is increasing evidence that spinal injuries are found at autopsy or MRI in abused children. However the prevalence of cervical spine injuries in children evaluated for abusive head trauma is unknown. We sought to determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible abusive head trauma. We also examined the relationship between cervical and brain MRI findings and selected study outcome categories.

MATERIALS AND METHODS

This study is a 3-year retrospective review of children evaluated for abusive head trauma. Inclusion criteria were: children with head trauma seen at our institution between 2008 and 2010, age younger than 36 months, availability of diagnostic-quality brain and cervical spine MRI, and child abuse team involvement because abusive head trauma was a possibility. A child abuse pediatrician and pediatric radiologists, all with board certification, were involved in data collection, image interpretation and data analysis. Statistical analysis was performed using Stata v12.1.

RESULTS

The study included 74 children (43 boys, 31 girls) with a mean age of 164 days (range, 20-679 days). Study outcomes were categorized as: n = 26 children with accidental head trauma, n = 38 with abusive head trauma (n = 18 presumptive AHT, n = 20 suspicious for AHT), and n = 10 with undefined head trauma. We found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and two had spinal cord edema; all three of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of abusive head trauma or help discriminate between accidental and abusive head trauma. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic-ischemic pattern. There was a statistically significant relationship between bilateral hypoxic-ischemic brain injury pattern and abusive head trauma (P < 0.05). In addition, the majority (81%) of children with bilateral hypoxic-ischemic brain injuries had cervical injuries.

CONCLUSION

Although detection of cervical spine injuries by MRI does not discriminate between accidental and abusive head trauma, it can help to distinguish a traumatic from non-traumatic intracranial subdural hemorrhage. Cervical MRI should be considered in children with acute intracranial bleeds and otherwise non-contributory history, physical examination and ophthalmological findings. There is a statistically significant relationship between diffuse hypoxic-ischemic brain injury patterns and abusive head trauma. The high incidence of cervical injuries in children with hypoxic-ischemic injuries suggests a causal relationship. Overall, increased utilization of brain and spine MRI in children being evaluated for abusive head trauma can be helpful.

Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

OBJECT

The appearance and evolution of neuroimaging abnormalities following abusive head trauma (AHT) is important for establishing the time frame over which these injuries might have occurred. From a legal perspective this frames the timing of the abuse and therefore identifies and excludes potential perpetrators. A previous pilot study involving 33 infants with AHT helped to refine the timing of these injuries but was limited by its small sample size. In the present study, the authors analyzed a larger group of 210 cases involving infants with AHT to chronicle the first appearance and evolution of radiological (CT, MRI) abnormalities.

METHODS

All children younger than 24 months admitted to the Penn State Hershey Medical Center with AHT over a 10-year period were identified from a medical record review; the time of injury was determined through an evaluation of the clinical records. All imaging studies were analyzed, and the appearance and evolution of abnormalities were chronicled on serial neuroimaging studies obtained in the days and weeks after injury.

RESULTS

One hundred five infants with specific injury dates and available imaging studies were identified; a subset of 43 children additionally had documented times of injury. In infants with homogeneously hyperdense subdural hematomas (SDHs) on initial CT scans, the first hypodense component appeared within the SDH between 0.3 and 16 days after injury, and the last hyperdense subdural component disappeared between 2 and 40 days after injury. In infants with mixed-density SDHs on initial scans, the last hyperdense component disappeared between 1 and 181 days. Parenchymal hypodensities appeared on CT scans performed as early as 1.2 hours, and all were visible within 27 hours after the injury. Rebleeding into SDHs was documented in 17 cases (16%) and was always asymptomatic. Magnetic resonance imaging of the brain was performed in 49 infants. Among those with SDH, 5 patterns were observed. Patterns I and II reflected homogeneous SDH; Pattern I (T1 hyperintensity and T2/FLAIR hypointensity, "early subacute") more commonly appeared on scans performed earlier after injury compared with Pattern II (T1 hyperintensity and T2/FLAIR hyperintensity, "late subacute"), although there was considerable overlap. Patterns III and IV reflected heterogeneous SDH; Pattern III contained relatively equal mixtures having different intensities, whereas Pattern IV had fluid that was predominantly T1 hypointense and T2/FLAIR hyperintense. Again, Pattern III more commonly appeared on scans performed earlier after injury compared with Pattern IV, although there was significant overlap.

CONCLUSIONS

These data extend the preliminary data reported by Dias and colleagues and provide a framework upon which injuries in AHT can be timed as well as the limitations on such timing estimates.

Severe spinal cord injury in craniocervical dislocation. Case-based update

BACKGROUND

Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals.

DISCUSSION

Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome.

PATIENTS AND METHODS

We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome.

CONCLUSIONS

In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children's parents.

Injuries of the Upper Cervical Spinal Column are Markers of Severe Forces in the First Two Years of Life

Cervical spinal column injuries occur uncommonly in infants and young toddlers, and rarely in the upper cervical spine. Any injury, when discovered at forensic autopsy, must be interpreted within the context of a complete case investigation, and available science. When severe upper cervical spinal column injury is detected, such as atlanto-occipital dislocation (AOD), atlanto-axial dislocation (AAD) or spinal cord transection, forensic pathologists commonly regard such trauma as a marker of significant forces. This retrospective study evaluated 60 cases of accidental and homicidal deaths occurring in the first 24 months of life and investigated by a large metropolitan medical examiner jurisdiction. All cases with AOD, AAD or spinal cord transection occurred under documented accidental circumstances, and all of those cases involved severe forces, including being struck by or run over by a car. While such high cervical spinal column pathology is not unusual when an infant or young toddler is struck by or run over by a motor vehicle, or other accidental circumstance involving severe forces, this discovery in a case of apparent natural death or death following alleged short fall or other commonplace activity of daily living should be considered highly suspect.

Abusive head trauma Part II: radiological aspects

Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.

CONCLUSION

The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Educational paper: Abusive Head Trauma part I. Clinical aspects

Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14-40 cases per 100,000 children under the age of 1 year. About 15-23% of these children die within hours or days after the incident. Studies among AHT survivors 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. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea.

CONCLUSION

AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously.

Spinal subdural hemorrhage in abusive head trauma: a retrospective study

PURPOSE

To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children.

MATERIALS AND METHODS

This study received prior approval from the Human Subjects Protection Office. Informed consent was waived. This study was HIPAA compliant. Two hundred fifty-two children aged 0-2 years treated for abusive head trauma at our institute between 1997 and 2009 were identified through retrospective chart review. A second group of 70 children aged 0-2 years treated at our institute for well-documented accidental trauma between 2003 and 2010 were also identified through retrospective chart review. All clinical data and cross-sectional imaging results, including computed tomographic and magnetic resonance imaging of the brain, spine, chest, abdomen, and pelvis, were reviewed for both of these groups. A Fisher exact test was performed to assess the statistical significance of the proportion of the spinal canal subdural hemorrhage in abusive head trauma versus that in accidental trauma.

RESULTS

In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours ± 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001).

CONCLUSION

Spinal canal subdural hemorrhage was present in more than 60% of children with abusive head trauma who underwent thoracolumbar imaging in this series but was rare in those with accidental trauma.

The "Shaken Baby" syndrome: pathology and mechanisms

The "Shaken Baby" syndrome (SBS) is the subject of intense controversy; the diagnosis has in the past depended on the triad of subdural haemorrhage (SDH), retinal haemorrhage and encephalopathy. While there is no doubt that infants do suffer abusive injury at the hands of their carers and that impact can cause catastrophic intracranial damage, research has repeatedly undermined the hypothesis that shaking per se can cause this triad. The term non-accidental head injury has therefore been widely adopted. This review will focus on the pathology and mechanisms of the three physiologically associated findings which constitute the "triad" and are seen in infants suffering from a wide range of non-traumatic as well as traumatic conditions. "Sub" dural bleeding in fact originates within the deep layers of the dura. The potential sources of SDH include: the bridging veins, small vessels within the dura itself, a granulating haemorrhagic membrane and ruptured intracranial aneurysm. Most neuropathologists do not routinely examine eyes, but the significance of this second arm of the triad in the diagnosis of Shaken Baby syndrome is such that it merits consideration in the context of this review. While retinal haemorrhage can be seen clinically, dural and subarachnoid optic nerve sheath haemorrhage is usually seen exclusively by the pathologist and only rarely described by the neuroradiologist. The term encephalopathy is used loosely in the context of SBS. It may encompass anything from vomiting, irritability, feeding difficulties or floppiness to seizures, apnoea and fulminant brain swelling. The spectrum of brain pathology associated with retinal and subdural bleeding from a variety of causes is described. The most important cerebral pathology is swelling and hypoxic-ischaemic injury. Mechanical shearing injury is rare and contusions, the hallmark of adult traumatic brain damage, are vanishingly rare in infants under 1 year of age. Clefts and haemorrhages in the immediate subcortical white matter have been assumed to be due to trauma but factors specific to this age group offer other explanations. Finally, examples of the most common causes of the triad encountered in clinical diagnostic and forensic practice are briefly annotated.

Head injury depth as an indicator of causes and mechanisms

OBJECTIVE

The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children <36 months of age with varying "greatest depths" of acute cranial injury.

METHODS

Children <36 months of age who were hospitalized with acute head trauma were recruited at multiple sites. Clinical and imaging data were collected, and caregivers underwent scripted interviews. Neurodevelopmental evaluations were completed 6 months after injury. Head trauma causes were categorized independently, and subject groups with varying greatest depths of injury were compared.

RESULTS

Fifty-four subjects were enrolled at 9 sites. Twenty-seven subjects underwent follow-up neurodevelopmental assessments 6 months after injury. Greatest depth of visible injury was categorized as scalp, skull, or epidural for 20 subjects, subarachnoid or subdural for 13, cortical for 10, and subcortical for 11. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < .001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury.

CONCLUSION

For children <3 years of age, head injury depth is a useful indicator of injury causes and mechanisms.

Abusive head trauma in infants and children

Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with abusive head trauma compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well. Spinal cord injury and secondary hypoxic ischemic injury can contribute to poor outcomes of victims. The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required. The American Academy of Pediatrics recommends that pediatricians develop skills in the recognition of signs and symptoms of abusive head injury, including those caused by both shaking and blunt impact, consult with pediatric subspecialists when necessary, and embrace a less mechanistic term, abusive head trauma, when describing an inflicted injury to the head and its contents.