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Fandak J, Markart S, Willems EP, Wildermuth S, Frauenfelder T, Fischer T, Dietrich TJ, Waelti SL. Prospective measurement of the width of cerebrospinal fluid spaces by cranial ultrasound in neurologically healthy children aged 0-19 months. BMC Pediatr 2024; 24:315. [PMID: 38714956 PMCID: PMC11075241 DOI: 10.1186/s12887-024-04797-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Ultrasound (US) is often the first method used to look for brain or cerebrospinal fluid (CSF) space pathologies. Knowledge of normal CSF width values is essential. Most of the available US normative values were established over 20 years ago, were obtained with older equipment, and cover only part of the age spectrum that can be examined by cranial US. This prospective study aimed to determine the normative values of the widths of the subarachnoid and internal CSF spaces (craniocortical, minimal and maximal interhemispheric, interventricular, and frontal horn) for high-resolution linear US probes in neurologically healthy infants and children aged 0-19 months and assess whether subdural fluid collections can be delineated. METHODS Two radiologists measured the width of the CSF spaces with a conventional linear probe and an ultralight hockey-stick probe in neurologically healthy children not referred for cranial or spinal US. RESULTS This study included 359 neurologically healthy children (nboys = 178, 49.6%; ngirls = 181, 50.4%) with a median age of 46.0 days and a range of 1-599 days. We constructed prediction plots, including the 5th, 50th, and 95th percentiles, and an interactive spreadsheet to calculate normative values for individual patients. The measurements of the two probes and the left and right sides did not differ, eliminating the need for separate normative values. No subdural fluid collection was detected. CONCLUSION Normative values for the widths of the subarachnoid space and the internal CSF spaces are useful for evaluating intracranial pathology, especially when determining whether an increase in the subarachnoid space width is abnormal.
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Affiliation(s)
- Jozef Fandak
- Department of Radiology and Nuclear Medicine, Children's Hospital of Eastern Switzerland, St. Gallen, 9006, Switzerland
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Stefan Markart
- Department of Radiology and Nuclear Medicine, Children's Hospital of Eastern Switzerland, St. Gallen, 9006, Switzerland
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Erik P Willems
- Clinical Trials Unit, Biostatistics, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Simon Wildermuth
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Thomas Frauenfelder
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tim Fischer
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Tobias J Dietrich
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Stephan L Waelti
- Department of Radiology and Nuclear Medicine, Children's Hospital of Eastern Switzerland, St. Gallen, 9006, Switzerland.
- Department of Radiology and Nuclear Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
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Koti AS, Lanis A, Finlayson S, Canny S, Feldman EA, Miller DE, Rosenwasser N, Scott AA, Wong SC, Feldman KW. Subdural hemorrhage, macrocephaly, rash, and developmental delay in an infant: A pathogenic variant in NLRP3 causes CINCA/NOMID. Am J Med Genet A 2023; 191:2825-2830. [PMID: 37548074 DOI: 10.1002/ajmg.a.63366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Subdural hemorrhages (SDHs) in children are most often observed in abusive head trauma (AHT), a distinct form of traumatic brain injury, but they may occur in other conditions as well, typically with clear signs and symptoms of an alternative diagnosis. We present a case of an infant whose SDH initially raised the question of AHT, but multidisciplinary evaluation identified multiple abnormalities, including rash, macrocephaly, growth failure, and elevated inflammatory markers, which were all atypical for trauma. These, along with significant cerebral atrophy, ventriculomegaly, and an absence of other injuries, raised concerns for a genetic disorder, prompting genetic consultation. Clinical trio exome sequencing identified a de novo likely pathogenic variant in NLRP3, which is associated with chronic infantile neurological, cutaneous, and articular (CINCA) syndrome, also known as neonatal-onset multisystem inflammatory disease (NOMID). He was successfully treated with interleukin-1 blockade, highlighting the importance of prompt treatment in CINCA/NOMID patients. This case also illustrates how atraumatic cases of SDH can be readily distinguished from AHT with multidisciplinary collaboration and careful consideration of the clinical history and exam findings.
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Affiliation(s)
- Ajay S Koti
- Safe Child and Adolescent Network, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Aviya Lanis
- Division of Rheumatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Samuel Finlayson
- Division of Genetic Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Susan Canny
- Division of Rheumatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Elana A Feldman
- Safe Child and Adolescent Network, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Danny E Miller
- Division of Genetic Medicine, Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Natalie Rosenwasser
- Division of Rheumatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Abbey A Scott
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stephen C Wong
- Division of Rheumatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kenneth W Feldman
- Safe Child and Adolescent Network, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
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3
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Rohde JF, Campbell J, Barbera J, Taylor E, Ramachandra A, Gegg C, Scherer A, Piatt J. Clinical factors associated with need for neurosurgical care in young children with imaging for macrocephaly: a case control study. BMC Pediatr 2023; 23:555. [PMID: 37925412 PMCID: PMC10625283 DOI: 10.1186/s12887-023-04379-2] [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: 06/28/2023] [Accepted: 10/20/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Macrocephaly is present in 2.3% of children with important neurosurgical conditions in the differential diagnosis. The objective of this study was to identify clinical associations with actionable imaging findings among children with head imaging for macrocephaly. METHODS We conducted a case-control study of head imaging studies ordered for macrocephaly among children 24 months and younger in a multistate children's health system. Four neurosurgeons reviewed the images, determining cases to be a 'concern' if neurosurgical follow-up or intervention was indicated. Electronic health records were reviewed to collect patient-level data and to determine if surgery was performed. Controls were matched 3:1 to cases of 'concern' in a multivariate model using conditional logistic regression. RESULTS In the study sample (n = 1293), 46 (4%) were concern cases, with 15 (1%) requiring surgery. Significant clinical factors associated with neurosurgical concern were bulging fontanel [aOR 7.47, (95% CI: 2.28-24.44), P < 0.001], prematurity [aOR 21.26, (95% CI: 3.76-120.21), P < 0.001], any delay [aOR 2.67, (95% CI: 1.13-6.27), P = 0.03], and head-weight Z-score difference (W_diff, defined as the difference between the Z-scores of head circumference and weight) [aOR 1.70, (95% CI: 1.22-2.37), P = 0.002]. CONCLUSIONS Head imaging for macrocephaly identified few patients with findings of concern and fewer requiring surgery. A greater head-weight Z-score difference appears to represent a novel risk factor for neurosurgical follow-up or intervention.
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Affiliation(s)
- Jessica F Rohde
- Division of General Pediatrics, Nemours Children's Hospital, 1600 Rockland Road, Wilmington, DE, 19803, USA.
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Jeffrey Campbell
- Division of Neurosurgery, Nemours Children's Hospital, Wilmington, DE, USA
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie Barbera
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elena Taylor
- Division of General Pediatrics, Nemours Children's Hospital, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Ashok Ramachandra
- Department of Radiology, Nemours Children's Hospital, Wilmington, DE, USA
| | - Christopher Gegg
- Division of Neurosurgery, Nemours Children's Hospital, Orlando, FL, USA
| | - Andrea Scherer
- Division of Neurosurgery, Nemours Children's Hospital, Orlando, FL, USA
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Children's Hospital, Wilmington, DE, USA
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Rosenbaum ARP, Jewell JL, Searns JB. Infant with Acute Onset Esotropia. Pediatr Rev 2023; 44:S55-S58. [PMID: 37777233 DOI: 10.1542/pir.2021-005330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
| | - Jerry L Jewell
- Department of Pediatrics
- Department of Neurology, University of Colorado, Aurora, CO
| | - Justin B Searns
- Department of Pediatrics
- Division of Hospital Medicine; Division of Infectious Diseases, Department of Pediatrics, University of Colorado, Aurora, CO
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Ho CY, Sankar M, Persohn S, Kralik SF, Graner B, Territo PR. Quantitative assessment of cerebrospinal fluid flow and volume in enlargement of the subarachnoid spaces of infancy using MRI. Pediatr Radiol 2023; 53:1919-1926. [PMID: 37100991 DOI: 10.1007/s00247-023-05659-w] [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: 11/10/2022] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The etiology of enlarged subarachnoid spaces of infancy is unknown; however, there is radiologic similarity with normal pressure hydrocephalus. Adults with normal pressure hydrocephalus have been shown to have altered cerebrospinal (CSF) flow through the cerebral aqueduct. OBJECTIVE To explore potential similarity between enlarged subarachnoid spaces of infancy and normal pressure hydrocephalus, we compared MRI-measured CSF flow through the cerebral aqueduct in infants with enlarged subarachnoid spaces of infancy to infants with normal brain MRIs. MATERIALS AND METHODS This was an IRB approved retrospective study. Clinical brain MRI examinations including axial T2 imaging and phase contrast through the aqueduct were reviewed for infants with enlarged subarachnoid spaces of infancy and for infants with a qualitatively normal brain MRI. The brain and CSF volumes were segmented using a semi-automatic technique (Analyze 12.0) and CSF flow parameters were measured (cvi42, 5.14). All data was assessed for significant differences while controlling for age and sex using analysis of covariance (ANCOVA). RESULTS Twenty-two patients with enlarged subarachnoid spaces (mean age 9.0 months, 19 males) and 15 patients with normal brain MRI (mean age 18.9 months, 8 females) were included. Volumes of the subarachnoid space (P < 0.001), lateral (P < 0.001), and third ventricles (P < 0.001) were significantly larger in infants with enlarged subarachnoid spaces of infancy. Aqueductal stroke volume significantly increased with age (P = 0.005), regardless of group. CONCLUSION CSF volumes were significantly larger in infants with enlarged subarachnoid spaces of infancy versus infants with a normal MRI; however, there was no significant difference in CSF flow parameters between the two groups.
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Affiliation(s)
- Chang Y Ho
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Meghana Sankar
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Scott Persohn
- Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Brian Graner
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Paul R Territo
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA
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Raissaki M, Adamsbaum C, Argyropoulou MI, Choudhary AK, Jeanes A, Mankad K, Mannes I, Van Rijn RR, Offiah AC. Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse. Pediatr Radiol 2023; 53:752-767. [PMID: 36856756 PMCID: PMC10027800 DOI: 10.1007/s00247-023-05611-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 03/02/2023]
Abstract
In infants without a history of trauma, subdural haemorrhages should raise the concern for an abusive head injury, particularly when they are associated with bridging vein clotting/rupture or with septations. However, non-haemorrhagic, fluid-appearing subdural collections (also called hygromas) may also be the result of abuse. Subdural collections have also been uncommonly observed in patients with benign enlargement of the subarachnoid spaces (BESS) and a few large-scale studies accurately investigate the incidence and the significance. Currently, there is a wide variation of practices in children with BESS and subdural collections. Due to the social risks associated with abuse evaluation and the perceived risk of radiation exposure, there might be a reluctance to fully evaluate these children in some centres. The diagnosis of physical abuse cannot be substantiated nor safely excluded in infants with BESS and subdural collection(s), without investigation for concomitant traumatic findings. The exact prevalence of occult injuries and abuse in these infants is unknown. In macrocephalic infants with subdural collections and imaging features of BESS, thorough investigations for abuse are warranted and paediatricians should consider performing full skeletal surveys even when fundoscopy, social work consult, and detailed clinical evaluation are unremarkable.
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Affiliation(s)
- Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Medical School, University of Crete, Crete, Greece.
| | - Catherine Adamsbaum
- Emeritus Pediatric Radiologist, Faculty of Medicine, Paris-Saclay University, 63 Rue Gabriel Péri, 94270, Le Kremlin Bicêtre, France
| | - Maria I Argyropoulou
- Department of Clinical Radiology and Imaging, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | - Inès Mannes
- Pediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin‑Bicêtre, France
| | - Rick R Van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, University of Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK
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Maruccia F, Tagliabue S, Fischer JB, Kacprzak M, Pérez-Hoyos S, Rosas K, Álvarez ID, Sahuquillo J, Durduran T, Poca MA. Transcranial optical monitoring for detecting intracranial pressure alterations in children with benign external hydrocephalus: a proof-of-concept study. NEUROPHOTONICS 2022; 9:045005. [PMID: 36405998 PMCID: PMC9670160 DOI: 10.1117/1.nph.9.4.045005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
SIGNIFICANCE Benign external hydrocephalus (BEH) is considered a self-limiting pathology with a good prognosis. However, some children present a pathological intracranial pressure (ICP) characterized by quantitative and qualitative alterations (the so-called B-waves) that can lead to neurological sequelae. AIM Our purpose was to evaluate whether there were cerebral hemodynamic changes associated with ICP B-waves that could be evaluated with noninvasive neuromonitoring. APPROACH We recruited eleven patients (median age 16 months, range 7 to 55 months) with BEH and an unfavorable evolution requiring ICP monitoring. Bedside, nocturnal monitoring using near-infrared time-resolved and diffuse correlation spectroscopies synchronized to the clinical monitoring was performed. RESULTS By focusing on the timing of different ICP patterns that were identified manually by clinicians, we detected significant tissue oxygen saturation ( StO 2 ) changes ( p = 0.002 ) and blood flow index (BFI) variability ( p = 0.005 ) between regular and high-amplitude B-wave patterns. A blinded analysis looking for analogs of ICP patterns in BFI time traces achieved 90% sensitivity in identifying B-waves and 76% specificity in detecting the regular patterns. CONCLUSIONS We revealed the presence of StO 2 and BFI variations-detectable with optical techniques-during ICP B-waves in BEH children. Finally, the feasibility of detecting ICP B-waves in hemodynamic time traces obtained noninvasively was shown.
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Affiliation(s)
- Federica Maruccia
- Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron Research Institute, Neurotraumatology and Neurosurgery Research Unit, Barcelona, Spain
- ICFO-Insitut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Susanna Tagliabue
- ICFO-Insitut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Jonas B. Fischer
- ICFO-Insitut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Barcelona, Spain
- HemoPhotonics S.L., Barcelona, Spain
| | - Michał Kacprzak
- ICFO-Insitut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Barcelona, Spain
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Warsaw, Poland
| | - Santi Pérez-Hoyos
- Vall d’Hebron Research Institute, Statistics and Bioinformatics Unit, Barcelona, Spain
| | - Katiuska Rosas
- Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron Research Institute, Neurotraumatology and Neurosurgery Research Unit, Barcelona, Spain
- Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Department of Neurosurgery and Pediatric Neurosurgery Unit, Barcelona, Spain
| | - Ignacio Delgado Álvarez
- Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Department of Pediatric Neuroradiology, Barcelona, Spain
| | - Juan Sahuquillo
- Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron Research Institute, Neurotraumatology and Neurosurgery Research Unit, Barcelona, Spain
- Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Department of Neurosurgery and Pediatric Neurosurgery Unit, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Turgut Durduran
- ICFO-Insitut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Maria A. Poca
- Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron Research Institute, Neurotraumatology and Neurosurgery Research Unit, Barcelona, Spain
- Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Department of Neurosurgery and Pediatric Neurosurgery Unit, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
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Imaging of Macrocephaly. Clin Perinatol 2022; 49:715-734. [PMID: 36113931 DOI: 10.1016/j.clp.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Macrocephaly is a common diagnosis in the pediatric population, particularly in the infantile time period. There is a wide range of causes of macrocephaly, from benign to malignant, for which imaging plays a key role in the diagnosis and clinical guidance. Our aim is to review the distinct and prevalent neuroimaging findings in the evaluation of the macrocephalic infant.
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Alshareef M, Tyler M, Litts C, Pearce J, Yazdani M, Eskandari R. Prevalence of Visible Subdural Spaces in Benign Enlargement of Subarachnoid Spaces in Infancy: A Retrospective Analysis Utilizing Magnetic Resonance Imaging. World Neurosurg 2022; 164:e973-e979. [PMID: 35636660 DOI: 10.1016/j.wneu.2022.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Benign Enlargement of the Subarachnoid Spaces in Infancy (BESSI) is a common finding during workup for progressive macrocephaly. BESSI has been associated with slightly higher prevalence of subdural (SD) spaces and a risk for developing subdural hematoma. This study utilizes fast brain magnetic resonance imaging (MRI) to investigate the prevalence of visible SD spaces in BESSI. METHODS A retrospective review was performed for all pediatric patients who underwent brain MRI for macrocephaly. Patients with a diagnosis of BESSI were included in the study. A total of 109 patients met the inclusion criteria. Patient demographics were collected, and images were reviewed for size of subarachnoid, visible SD spaces, and ventricle size. Descriptive and inferential statistics were performed. RESULTS The average age was 8 ± 4.6 months, 64 (59%) were male, and 55 patients had no previous medical history (50%). Sixty-seven percent of all patients were identified to have visible SD spaces. Eleven patients had confirmed SD hematomas; 1 patient was deemed to have abusive head trauma. Visible SD spaces were associated with younger age (6.9 months). Thirty-one patients with visible SD spaces had follow-up MRI, with complete resolution by 33 months. CONCLUSIONS BESSI is a self-limiting pathology that has been associated with visible SD spaces and potential risk for SD hemorrhages. We report a high prevalence of visible SD spaces within BESSI through utilization of fast brain MRI. These spaces may contribute to the higher rate of incidental subdural hematoma in this population.
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Affiliation(s)
- Mohammed Alshareef
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael Tyler
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christopher Litts
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jackson Pearce
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Milad Yazdani
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
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10
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Is external hydrocephalus a possible differential diagnosis when child abuse is suspected? Editorial. Acta Neurochir (Wien) 2022; 164:1173-1174. [PMID: 34767094 DOI: 10.1007/s00701-021-04792-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 10/19/2022]
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11
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Scheller J, Wester K. Is external hydrocephalus a possible differential diagnosis when child abuse is suspected? Acta Neurochir (Wien) 2022; 164:1161-1172. [PMID: 33710381 PMCID: PMC8967805 DOI: 10.1007/s00701-021-04786-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/22/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Criteria for diagnosing abusive head trauma (AHT) or "shaken baby syndrome" are not well defined; consequently, these conditions might be diagnosed on failing premises. METHODS The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)-mean age 5.1 month, without age difference between genders. RESULTS Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). CONCLUSIONS BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors' experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.
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Affiliation(s)
- Joseph Scheller
- Neurologist in Private Practice, 600 Reisterstown Rd #301, Baltimore, MD, 21208, USA
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, N 5021, Bergen, Norway.
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Holste KG, Wieland CM, Ibrahim M, Parmar HA, Saleh S, Garton HJL, Maher CO. Subdural hematoma prevalence and long-term developmental outcomes in patients with benign expansion of the subarachnoid spaces. J Neurosurg Pediatr 2022; 29:536-542. [PMID: 35148506 DOI: 10.3171/2021.12.peds21436] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Benign expansion of the subarachnoid spaces (BESS) is a condition seen in macrocephalic infants. BESS is associated with mild developmental delays which tend to resolve within a few years. It is accepted that patients with BESS are at increased risk of spontaneous subdural hematomas (SDHs), although the exact pathophysiology is not well understood. The prevalence of spontaneous SDH in BESS patients is poorly defined, with only a few large single-center series published. In this study the authors aimed to better define BESS prevalence and developmental outcomes through the longitudinal review of a large cohort of BESS patients. METHODS A large retrospective review was performed at a single institution from 1995 to 2020 for patients 2 years of age or younger with a diagnosis of BESS by neurology or neurosurgery and head circumference > 85th percentile. Demographic data, head circumference, presence of developmental delay, occurrence of SDH, and need for surgery were extracted from patient charts. The subarachnoid space (SAS) size was measured from the available MR images, and the sizes of those who did and did not develop SDH were compared. RESULTS Free text search revealed BESS mentioned within the medical records of 1410 of 2.6 million patients. After exclusion criteria, 480 patients remained eligible for the study. Thirty-two percent (n = 154) of patients were diagnosed with developmental delay, most commonly gross motor delay (53%). Gross motor delay resolved in 86% of patients at a mean age of 22.2 months. The prevalence of spontaneous SDH in this BESS population over a period of 25 years was 8.1%. There was no significant association between SAS size and SDH formation. CONCLUSIONS This study represents results for one of the largest cohorts of patients with BESS at a single institution. Gross motor delay was the most common developmental delay diagnosed, and a majority of patients had resolution of their delay. These data support that children with BESS have a higher prevalence of SDH than the general pediatric population, although SAS size was not significantly associated with SDH development.
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Affiliation(s)
| | | | - Mohannad Ibrahim
- 3Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Hemant A Parmar
- 3Department of Radiology, University of Michigan, Ann Arbor, Michigan
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13
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Vaslow DF. Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants. Neuroradiol J 2022; 35:53-66. [PMID: 34167377 PMCID: PMC8826291 DOI: 10.1177/19714009211026904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.
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Affiliation(s)
- Dale F Vaslow
- Department of Radiology, Harry S.
Truman Veterans Administration Hospital, Columbia, MO, USA,Dale F Vaslow, 2504 Lenox Place, Columbia,
MO 65203, USA.
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14
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Wongkittichote P, Kondis JS, Peglar LM, Strahle JM, Miller-Thomas M, Abell KB. Pathogenic variant in NFIA associated with subdural hematomas mimicking nonaccidental trauma. Am J Med Genet A 2022; 188:1538-1544. [PMID: 35006644 DOI: 10.1002/ajmg.a.62647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/18/2021] [Accepted: 12/26/2021] [Indexed: 11/09/2022]
Abstract
Subdural hematoma (SDH) in infants raises the concern for nonaccidental trauma (NAT), especially when presenting with associated injuries. However, isolated SDH could be caused by multiple etiologies. NFIA (MIM# 600727) encodes nuclear factor I A protein (NFI-A), a transcription factor which plays important roles in gliogenesis. Loss-of-function variants in NFIA are associated with autosomal dominant brain malformations with or without urinary tract defects (MIM# 613735). Intracranial hemorrhage of various types besides SDH has been reported in patients with this condition. Here, we report a patient with a heterozygous novel NFIA pathogenic variant affecting splicing who initially presented with SDH concerning for NAT. We also review previous NFIA-related disorder cases with intracranial hemorrhage. This report emphasizes the importance of genetic evaluation in infants presenting with isolated SDH.
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Affiliation(s)
- Parith Wongkittichote
- Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jamie S Kondis
- Child Abuse Pediatrics, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lindsay M Peglar
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Michelle Miller-Thomas
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katherine B Abell
- Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
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15
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Miyabayashi H, Seto H, Tanabe S, Saito K, Morioka I. An infant with benign enlargement of the subarachnoid space with subdural hemorrhages. Pediatr Int 2022; 64:e15292. [PMID: 36259332 DOI: 10.1111/ped.15292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/17/2022] [Accepted: 06/26/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Hiroki Seto
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Satomi Tanabe
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuya Saito
- Department of Pediatrics, Kasukabe Medical Center, Kasukabe, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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16
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Infantile Macrocephaly: Complicated Familial Benign Enlargement of Subarachnoid Space in Twins of Suspected Nonaccidental Injury. World Neurosurg 2021; 157:67-68. [PMID: 34624522 DOI: 10.1016/j.wneu.2021.09.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022]
Abstract
A 3-month-old first of dizygotic male twins, born at 34 + 5 weeks gestational age, presented with a 4-week history of increasing head circumference and vomiting. He had a tense anterior fontanelle and a head circumference above the 97th percentile. Magnetic resonance imaging showed large bilateral subdural collection with hemosiderin deposits suggestive of hemorrhage. Nine days of bilateral subdural drainage reduced the collection size and blood load. On postoperative day 16, magnetic resonance imaging confirmed persistent but smaller subdural collections, unmasking the underlying subarachnoid space enlargement. On day 18, a right subdural-peritoneal valveless shunt was inserted as definitive treatment. As part of a nonaccidental injury investigation, Twin 2 was also found to have macrocephaly secondary to benign enlargement of subarachnoid space, which was managed conservatively. Benign enlargement of subarachnoid space has an assumed autosomal/multifactorial inheritance and predisposes to subdural hemorrhage. Ultimately, no safeguarding issues were raised. Both twins continued to be neurologically stable at 2-year follow-up with head circumferences between the 98th and 99th percentiles.
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17
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Neurodevelopmental profile in children with benign external hydrocephalus syndrome. A pilot cohort study. Childs Nerv Syst 2021; 37:2799-2806. [PMID: 33973055 DOI: 10.1007/s00381-021-05201-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The management of children with benign external hydrocephalus (BEH) remains controversial. Most BEH children do well in the long-term, but a substantial number have temporary or permanent psychomotor delays. The study aims to assess the prevalence and pattern of neurodevelopmental delay in a cohort of children with BEH. METHODS We conducted a cohort study of 42 BEH children (30 boys and 12 girls, aged 6 to 38 months). A pediatric neurosurgeon performed a first clinical evaluation to confirm/reject the diagnosis according to the clinical features and neuroimaging studies. Two trained evaluators assessed the child's psychomotor development using the third edition of the Bayley Scales of Infant and Toddler Development (Bayley-III). Developmental delay was defined as a scaled score < 7 according to the simple scale and/or a composite score < 85. RESULTS Eighteen children (43%) presented statistically lower scores in the gross motor and composite motor of the Bayley-III scales compared to their healthy peers. CONCLUSION In BEH, it is important to establish a diagnostic algorithm that helps to discriminate BEH patients that have self-limiting delays from those at risk of a persistent delay that should be referred for additional studies and/or interventions that might improve the natural evolution of a disease with high impact on the children and adult's quality of life.
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18
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Bryant JP, Hernandez NE, Niazi TN. Macrocephaly in the Primary Care Provider's Office. Pediatr Clin North Am 2021; 68:759-773. [PMID: 34247707 DOI: 10.1016/j.pcl.2021.04.004] [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] [Indexed: 11/17/2022]
Abstract
Macrocephaly is commonly encountered in the primary care provider's office. It is defined as an occipitofrontal circumference that is greater than 2 standard deviations above the mean for the child's given age. Macrocephaly is a nonspecific clinical finding that may be benign or require further evaluation. An algorithmic approach is useful for aiding in the clinical decision-making process to determine if further evaluation with neuroimaging is warranted. Abnormal findings may signify a harmful underlying cause, requiring referral to a genetic specialist or neurosurgeon.
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Affiliation(s)
- Jean-Paul Bryant
- Miller School of Medicine, University of Miami, 1600 NW 10th Avenue #1140, Miami, FL 33136, USA
| | - Nicole E Hernandez
- Division of Pediatric Neurosurgery, Brain Institute, Nicklaus Children's Hospital, 3100 SW 62nd Avenue Suite 3109, Miami, FL 33155, USA
| | - Toba N Niazi
- Miller School of Medicine, University of Miami, 1600 NW 10th Avenue #1140, Miami, FL 33136, USA; Division of Pediatric Neurosurgery, Brain Institute, Nicklaus Children's Hospital, 3100 SW 62nd Avenue Suite 3109, Miami, FL 33155, USA.
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19
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Green J, Rao V, Currie M. D2-Hydroxyglutaric Aciduria Type II with Subdural Hemorrhage Identified in a 3-Month-Old Infant: A Case Report. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1716566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractSubdural hemorrhage in association with D2-hydroxyglutaric aciduria (D2-HGA) Type II has only been described once in the medical literature in a 15-month-old child (1). Our case report describes a much younger 3-month-old infant previously diagnosed with D2-HGA Type II, who presented clinically with seizures and identified to have bilateral subdural hematomas concerning for possible physical abuse. This case report discusses the genetic diagnosis of D2-HGA and interpretation of subdural hemorrhage in context of evaluating possible physical abuse concerns. When an underlying medical condition is known to be present and a child presents with findings that may be concerning for physical abuse, it is critical to consider the possibility that the underlying medical condition may contribute to or may be the cause of the findings.
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Affiliation(s)
- Jennie Green
- Department of Norton Children's Pediatric Protection Specialists, Norton Children's Medical Group, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Vinod Rao
- Department of Norton Children's Pediatric Protection Specialists, Norton Children's Medical Group, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Melissa Currie
- Department of Norton Children's Pediatric Protection Specialists, Norton Children's Medical Group, School of Medicine, University of Louisville, Louisville, Kentucky, United States
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20
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Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:529-540. [PMID: 33908266 DOI: 10.2214/ajr.21.25655] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
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21
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Abstract
Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.
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Affiliation(s)
- Marguerite M Caré
- Division of Pediatric Neuroradiology, Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
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22
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Co-occurring hydrocephalus in autism spectrum disorder: a Danish population-based cohort study. J Neurodev Disord 2021; 13:19. [PMID: 33910498 PMCID: PMC8082886 DOI: 10.1186/s11689-021-09367-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 04/15/2021] [Indexed: 12/21/2022] Open
Abstract
Background The association between autism spectrum disorder and hydrocephalus is not well understood, despite demonstrated links between autism spectrum disorder and cerebrospinal fluid abnormalities. Based on the hypothesis that autism spectrum disorder and hydrocephalus may, at least in some cases, be two manifestations of a shared congenital brain pathology, we investigated the potential association between autism spectrum disorder and hydrocephalus in a large Danish population-based cohort. Methods Patients and controls were obtained from the Lundbeck Foundation Initiative for Integrative Psychiatric Research iPSYCH2012 case-cohort, which includes all patients with selected psychiatric disorders born in Denmark 1981–2005 along with randomly selected population controls (end of follow-up, December 31, 2016). The associations between individual psychiatric disorders and hydrocephalus were estimated using binary logistic regression with adjustment for age and sex. Results The cohort consisted of 86,571 individuals, of which 14,654 were diagnosed with autism spectrum disorder, 28,606 were population controls, and the remaining were diagnosed with other psychiatric disorders. We identified 201 hydrocephalus cases; 68 among autism spectrum disorder patients and 40 among controls (OR 3.77, 95% CI 2.48–5.78), which corresponds to an absolute risk of 0.46 % (i.e. approximately one in 217 children with autism spectrum disorder had co-occurring hydrocephalus). The autism spectrum disorder-hydrocephalus association was significant over the entire subgroup spectrum of autism spectrum disorder. Conclusions Given the considerable risk of hydrocephalus among patients with autism spectrum disorder, we suggest that patients with autism spectrum disorder should be evaluated for co-occurring hydrocephalus on a routine basis as timely neurosurgical intervention is important. Likewise, attention must be paid to traits of autism spectrum disorder in children with hydrocephalus. The results of this study call for future investigations on a potential shared aetiology between hydrocephalus and autism spectrum disorder, including the role abnormal CSF dynamics in the pathogenesis of autism spectrum disorder. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-021-09367-0.
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23
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Spontaneous resolution of large subdural hematoma with midline shift: a case report. Childs Nerv Syst 2021; 37:703-705. [PMID: 32561984 DOI: 10.1007/s00381-020-04733-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
Subdural hematomas with mass effect and midline shift are typically offered urgent surgical evacuation. The authors report a 6-month-old baby who was referred for macrocephaly and found to have a large subdural hematoma with midline shift. Given her lack of symptoms and normal neurological examination, the patient was observed without neurosurgical intervention. She remained asymptomatic, and serial brain imaging showed progressive decrease of the subdural hemorrhage and complete resolution of midline shift. This case is presented to alert neurosurgeons that observation of a large subdural hematoma may rarely be appropriate in babies with open fontanelles.
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24
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do Valle DA, Santos MLSF, Zeny MS, Cordeiro ML. Pediatric Anti-N-methyl-D-aspartate Receptor Encephalitis Mimicking Glutaric Aciduria Type 1: A Case Report. Front Neurol 2020; 11:587324. [PMID: 33193053 PMCID: PMC7649249 DOI: 10.3389/fneur.2020.587324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/17/2020] [Indexed: 01/17/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated disease that induces a wide spectrum of symptoms, especially in toddlers. These include acute-onset movement disorders, with neurological regression, and other associated neurological symptoms. Anti-NMDAR encephalitis remains a diagnostic challenge, especially in toddlers, with better prognosis associated with early treatment. We report the case of a 15-months-old boy who initially presented with vomiting and later with acute-onset dystonia after the administration of antiemetics. Within 14 days, the patient developed neuropsychomotor developmental regression and worsening dystonia. After ruling out an acute dystonic reaction and glutaric acidemia type 1 (GA-1), a final diagnosis of anti-NMDAR encephalitis was made. The patient responded well to immunomodulatory therapy. The present case underscores the importance of early treatment for patient prognosis and of including anti-NMDAR encephalitis in the differential diagnosis of acute-onset movement disorders.
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Affiliation(s)
- Daniel Almeida do Valle
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Mara Lúcia Schmitz Ferreira Santos
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Michelle Silva Zeny
- Department of Neurology, Children's Hospital Pequeno Príncipe, Curitiba, Brazil.,Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil
| | - Mara L Cordeiro
- Faculdades Pequeno Principe, Curitiba, Brazil.,Research Institute Pelé Pequeno Príncipe, Curitiba, Brazil.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, LA, United States
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25
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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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26
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Yamaoka Y, Fujiwara T, Fujino Y, Matsuda S, Fushimi K. Response to the Letter to Editor: "Do Inter-Country Differences in the Frequency of Abusive Head Trauma Reflect Different Proportions of Overdiagnosis of Abuse or True Differences in Abuse?". J Epidemiol 2020; 30:278-279. [PMID: 31178473 PMCID: PMC7217685 DOI: 10.2188/jea.je20190106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Yui Yamaoka
- Center on Child Abuse and Neglect, University of Oklahoma Health Sciences Center.,Department of Global Health Promotion, Tokyo Medical and Dental University
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health.,Data Science Center of Occupational Health, University of Occupational and Environmental Health
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University
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27
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Zahl SM, Wester K, Gabaeff S. Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma. Acta Paediatr 2020; 109:659-666. [PMID: 31637736 PMCID: PMC7154632 DOI: 10.1111/apa.15072] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022]
Abstract
AIM Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants. METHODS Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature. RESULTS Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children. CONCLUSION Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.
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Affiliation(s)
| | - Knut Wester
- Department of Clinical Medicine K1University of BergenBergenNorway
- Department of NeurosurgeryHaukeland University HospitalBergenNorway
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28
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Diagnostica per immagini dell’idrocefalo del bambino. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)43300-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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29
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Wester K. Two Infant Boys Misdiagnosed as "Shaken Baby" and Their Twin Sisters: A Cautionary Tale. Pediatr Neurol 2019; 97:3-11. [PMID: 31147228 DOI: 10.1016/j.pediatrneurol.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/06/2019] [Accepted: 02/27/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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30
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Sampson MA, Berg AD, Huber JN, Olgun G. Necessity of Intracranial Imaging in Infants and Children With Macrocephaly. Pediatr Neurol 2019; 93:21-26. [PMID: 30704866 DOI: 10.1016/j.pediatrneurol.2018.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/18/2018] [Accepted: 10/27/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Macrocephaly is frequently encountered in pediatrics and often leads to imaging. There are no recommendations from the American Academy of Pediatrics or the American College of Radiology providing imaging guidelines for macrocephaly. The goal of this study is to identify risk factors for pathologic macrocephaly and to aid the clinician in identifying patients that would benefit from imaging. METHODS We conducted a medical record review throughout a multistate health care system, Sanford Health, from January 1, 2012 to December 31, 2016. Patients with macrocephaly were identified by problem list in children aged less than 36 months. Data collection included basic demographics, imaging modality, developmental delay, prematurity, seizures, focal neurological symptoms, family history of macrocephaly, sedation used, and sedation complications. RESULTS A total of 169 patients were included in the analysis. Imaging modalities included 39 magnetic resonance imagings (23.1%), 47 cranial computed tomographies (27.8%), and 83 head ultrasounds (49.1%). Imaging results demonstrated 13 abnormal studies with five of those studies being abnormal with high clinical yield. Patients with abnormal studies were more likely to have developmental delay (P = 0.04) or neurological symptoms (P = 0.015). Positive family history of macrocephaly was predictive of normal imaging (P = 0.004). There were no sedation complications. CONCLUSIONS Intracranial imaging does not appear to be necessary in children with no risk factors and or a positive family history of macrocephaly. Risk factors such as developmental delay or neurological symptoms could identify children at risk for imaging abnormalities that require further management.
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Affiliation(s)
- Megan A Sampson
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota
| | - Aaron D Berg
- University of South Dakota Sanford School of Medicine, Vermillion, South Dakota; Sanford USD Medical Center, Sioux Falls, South Dakota
| | - Jody N Huber
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota
| | - Gokhan Olgun
- Department of Pediatrics, Sanford USD Medical Center, Sanford Children's Hospital, Sioux Falls, South Dakota; University of South Dakota Sanford School of Medicine, Vermillion, South Dakota.
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31
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Wittschieber D, Karger B, Pfeiffer H, Hahnemann ML. Understanding Subdural Collections in Pediatric Abusive Head Trauma. AJNR Am J Neuroradiol 2019; 40:388-395. [PMID: 30523144 PMCID: PMC7028666 DOI: 10.3174/ajnr.a5855] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/16/2018] [Indexed: 11/07/2022]
Abstract
Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.
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Affiliation(s)
- D Wittschieber
- From the Institute of Legal Medicine (D.W., B.K., H.P.), University Hospital Münster, Münster, Germany
- Institute of Legal Medicine (D.W.), Friedrich Schiller University Jena, Jena, Germany
| | - B Karger
- From the Institute of Legal Medicine (D.W., B.K., H.P.), University Hospital Münster, Münster, Germany
| | - H Pfeiffer
- From the Institute of Legal Medicine (D.W., B.K., H.P.), University Hospital Münster, Münster, Germany
| | - M L Hahnemann
- Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.L.H.), University Hospital Essen, Essen, Germany
- Department of Neuroradiological Diagnostics and Intervention (M.L.H.), Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Zahl SM, Egge A, Helseth E, Skarbø AB, Wester K. Quality of life and physician-reported developmental, cognitive, and social problems in children with benign external hydrocephalus-long-term follow-up. Childs Nerv Syst 2019; 35:245-250. [PMID: 30523438 PMCID: PMC6351505 DOI: 10.1007/s00381-018-4016-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/28/2018] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Benign external hydrocephalus (BEH) is characterized by too rapidly increasing head circumference in infants, combined with typical neuroimaging findings. Psychomotor developmental delay is typically seen during the first few years of life; after that, the children's development assumedly normalizes. However, little is known about the long-term effects of BEH. METHODS In this retrospective population-based study, children diagnosed with BEH during the years 1994-2003 in Southern Norway were asked to participate. Included patients (age 8-18 years old) and their parents answered the PedsQL questionnaire. The patient's family physicians contributed by giving information from medical records, with special emphasis on developmental, cognitive, and social function. RESULTS One hundred seventy-six children were identified with BEH. One hundred three patients and 86 parents completed the PedsQL questionnaire. Supplemental medical information for 142 of the patients was received, mainly from their family physicians. Children and adolescents with BEH score themselves better than the normative mean on health-related quality of life, while the parents score their BEH children within the normative mean, except for the school functioning subgroup, where they score significantly lower. Various developmental, physical, and social problems are reported, like mental retardation, speech problems, epilepsy, motor impairment, psychiatric disorders, and cognitive difficulties. Among these patients, there is a discrepancy in some areas between the child-reported and parent-reported quality of life. CONCLUSIONS Children and adolescents who were diagnosed with BEH during infancy generally do well. However, for some patients, there appear to be various developmental, social, and cognitive problems, and they seem to struggle more in school than their healthy peers.
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Affiliation(s)
- Sverre Morten Zahl
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.
- Department of Ear, Nose and Throat, Aalesund Hospital, N-6026, Aalesund, Norway.
| | - Arild Egge
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne-Britt Skarbø
- Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Epidemiology of subdural haemorrhage during infancy: A population-based register study. PLoS One 2018; 13:e0206340. [PMID: 30379890 PMCID: PMC6209227 DOI: 10.1371/journal.pone.0206340] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022] Open
Abstract
Objectives To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse. Methods A Swedish population-based register study comprising infants born between 1997 and 2014, 0–1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0–6 and 7–365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis. Results Incidence of SDH was 16·5 per 100 000 infants (n = 306). Median age was 2·5 months. For infants older than one week, the median age was 3·5 months. Case fatality was 6·5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0–6 days, having a perinatal risk profile. For infants aged 7–365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age. Conclusions The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.
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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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The Child With Macrocephaly: Differential Diagnosis and Neuroimaging Findings. AJR Am J Roentgenol 2018; 210:848-859. [DOI: 10.2214/ajr.17.18693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hansen JB, Frazier T, Moffatt M, Zinkus T, Anderst JD. Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces. J Neurosurg Pediatr 2018; 21:31-37. [PMID: 29099352 DOI: 10.3171/2017.7.peds17317] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs. METHODS The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs. RESULTS Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08-0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03-0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5-7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05-0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms. CONCLUSIONS The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.
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Affiliation(s)
| | | | | | - Timothy Zinkus
- 2Radiology, Children's Mercy Hospital, Kansas City, Missouri
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Abstract
BACKGROUND Shaken baby syndrome is a common and devastating disease in infants. In spite of its frequency, many controversies persist, regarding the pathophysiology, diagnosis, and management. AIM OF THE STUDY We reviewed several salient and challenging issues related to SBS, like its pathogenesis, predisposing factors, differential diagnosis, and prevention programs. MATERIAL AND METHODS We derive arguments from the literature and from our prospective registry of accidental and non-accidental traumas in infants. CONCLUSIONS Much remains to be understood in SBS, and prevention programs for this entirely man-made disaster are still in their infancy. Pediatric neurosurgeons should be involved actively in the medical management and research on SBS.
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Affiliation(s)
- Matthieu Vinchon
- Department of Pediatric Neurosurgery, University Hospital, Hôpital Roger Salengro, 59037, Lille Cedex, France.
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Laurent-Vannier A, Rambaud C, Levin HS. Letter to the Editor. Subdural collections in infants: trauma or not trauma? J Neurosurg Pediatr 2017; 20:302-303. [PMID: 28598264 DOI: 10.3171/2017.3.peds17109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anne Laurent-Vannier
- France SBS, Saint-Maurice Hospitals, Saint Maurice, France.,APHP, CHU Raymond Poincaré, Service d'Anatomie Pathologique et Médecine Legale, Garches, France.,Université Versailles-St Quentin, Faculté de Médecine, Versailles, France; and.,Baylor College of Medicine, Houston, TX
| | - Caroline Rambaud
- France SBS, Saint-Maurice Hospitals, Saint Maurice, France.,APHP, CHU Raymond Poincaré, Service d'Anatomie Pathologique et Médecine Legale, Garches, France.,Université Versailles-St Quentin, Faculté de Médecine, Versailles, France; and.,Baylor College of Medicine, Houston, TX
| | - Harvey S Levin
- France SBS, Saint-Maurice Hospitals, Saint Maurice, France.,APHP, CHU Raymond Poincaré, Service d'Anatomie Pathologique et Médecine Legale, Garches, France.,Université Versailles-St Quentin, Faculté de Médecine, Versailles, France; and.,Baylor College of Medicine, Houston, TX
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Evaluation of the Hypothesis That Choking/ALTE May Mimic Abusive Head Trauma. Acad Pediatr 2017; 17:362-367. [PMID: 28017711 DOI: 10.1016/j.acap.2016.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/26/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH. METHODS We performed a 5-year retrospective case-control study of children <2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries. RESULTS Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury. CONCLUSIONS ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.
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Fingarson AK, Ryan ME, McLone SG, Bregman C, Flaherty EG. Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma. J Neurosurg Pediatr 2017; 19:254-258. [PMID: 27885942 DOI: 10.3171/2016.8.peds16146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Benign external hydrocephalus (BEH) is an enlargement of the subarachnoid spaces (SASs) that can be seen in young children. It is controversial whether children with BEH are predisposed to developing subdural hemorrhage (SDH) with or without trauma. This issue is clinically relevant as a finding of unexplained SDH raises concerns about child abuse and often prompts child protection and law enforcement investigations. METHODS This retrospective study included children (1-24 months of age) who underwent head CT scanning after an accidental fall of less than 6 feet. Head CT scans were reviewed, cranial findings were documented, and the SAS was measured and qualitatively evaluated. Enlarged SAS was defined as an extraaxial space (EAS) greater than 4 mm on CT scans. Clinical measurements of head circumference (HC) were noted, and the head circumference percentile was calculated. The relationship between enlarged SAS and HC percentile, and enlarged SAS and intracranial hemorrhage (ICH), were investigated using bivariate analysis. RESULTS Of the 110 children included in this sample, 23 had EASs greater than 4 mm. The mean patient age was 6.8 months (median 6.0 months). Thirty-four patients (30.9%) had ICHs, including subarachnoid/subpial (6.2%), subdural (6.2%), epidural (5.0%), and unspecified extraaxial hemorrhage (16.5%). Enlarged SAS was positively associated with subarachnoid/subpial hemorrhage; there was no association between enlarged SASs and either SDH or epidural hemorrhage. A larger SAS was positively associated with larger HC percentile; however, HC percentile was not independently associated with ICH. CONCLUSIONS Enlarged SAS was not associated with SDH, but was associated with other ICHs. The authors' findings do not support the theory that BEH predisposes children to SDH with minor accidental trauma.
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Affiliation(s)
| | - Maura E Ryan
- Medical Imaging, Division of Neuroradiology; and
| | - Suzanne G McLone
- Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - Emalee G Flaherty
- Departments of 1 Pediatrics, Division of Child Abuse Pediatrics, and
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Core curriculum illustration: brain-subdural hemorrhage in non-accidental trauma. Emerg Radiol 2016; 23:309-11. [PMID: 27126582 DOI: 10.1007/s10140-016-1395-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 04/01/2016] [Indexed: 10/21/2022]
Abstract
This is the 19 installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.aseronline.org/curriculum/toc.htm .
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