1
|
Miller DC, Stacy CC, Duff DJ, Guo S, Morse P. Neuropathology and Ophthalmological Pathology of Fatal Central Nervous System Injuries in Young Children: Forensic Neuropathology of Deaths of Children Under Age 2, 2008-2016, in Central Missouri. J Neuropathol Exp Neurol 2022; 81:854-864. [PMID: 36094646 DOI: 10.1093/jnen/nlac083] [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: 11/13/2022] Open
Abstract
Nonaccidental head injuries are significant causes of morbidity and mortality among young children. Despite broad agreement among medical experts, controversies remain over diagnostic criteria, including from autopsies, because of opinions expressed by a small group of expert witnesses who testify for defendants in suspected child homicide cases. We reviewed 249 autopsies in children 2 years old and younger from the files of our Medical Examiner office in the University of Missouri School of Medicine done between January 1, 2008 and December, 31, 2016. Because of gradually instituted mandatory examination of spinal cords and retinas, we had 127 autopsies with brain examinations by a neuropathologist plus retinal examinations of which 67 also had spinal cord examinations. Results were correlated with clinical records, police and EMS reports, and imaging. We found that subdural hematomas, cerebral edema, and retinal hemorrhages were mostly limited to autopsy findings in children who suffered from fatal head trauma, whether accidental (3 cases) or inflicted (14); they were not encountered in cases of homicide by other mechanisms or from natural diseases including infections, brain tumors, SIDS/SUID, or SUDC. Two cases with no other evidence of head trauma had focal retinal hemorrhages. We advocate for examination of retinas and spinal cords in all autopsies of children in this age group.
Collapse
Affiliation(s)
- Douglas C Miller
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - C Christopher Stacy
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA.,Office of the Chief Medical Examiner of Boone and Callaway Counties, Columbia, Missouri, USA
| | - Deiter J Duff
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA.,Office of the Chief Medical Examiner of Boone and Callaway Counties, Columbia, Missouri, USA
| | - Shunhua Guo
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Patrick Morse
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, Missouri, USA
| |
Collapse
|
2
|
Bartnik-Olson BL, Alger JR, Babikian T, Harris AD, Holshouser B, Kirov II, Maudsley AA, Thompson PM, Dennis EL, Tate DF, Wilde EA, Lin A. The clinical utility of proton magnetic resonance spectroscopy in traumatic brain injury: recommendations from the ENIGMA MRS working group. Brain Imaging Behav 2021; 15:504-525. [PMID: 32797399 PMCID: PMC7882010 DOI: 10.1007/s11682-020-00330-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Proton (1H) magnetic resonance spectroscopy provides a non-invasive and quantitative measure of brain metabolites. Traumatic brain injury impacts cerebral metabolism and a number of research groups have successfully used this technique as a biomarker of injury and/or outcome in both pediatric and adult TBI populations. However, this technique is underutilized, with studies being performed primarily at centers with access to MR research support. In this paper we present a technical introduction to the acquisition and analysis of in vivo 1H magnetic resonance spectroscopy and review 1H magnetic resonance spectroscopy findings in different injury populations. In addition, we propose a basic 1H magnetic resonance spectroscopy data acquisition scheme (Supplemental Information) that can be added to any imaging protocol, regardless of clinical magnetic resonance platform. We outline a number of considerations for study design as a way of encouraging the use of 1H magnetic resonance spectroscopy in the study of traumatic brain injury, as well as recommendations to improve data harmonization across groups already using this technique.
Collapse
Affiliation(s)
| | - Jeffry R Alger
- Departments of Neurology and Radiology, University of California Los Angeles, Los Angeles, CA, USA
- NeuroSpectroScopics LLC, Sherman Oaks, Los Angeles, CA, USA
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Talin Babikian
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
| | - Ashley D Harris
- Department of Radiology, University of Calgary, Calgary, Canada
- Child and Adolescent Imaging Research Program, Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Barbara Holshouser
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ivan I Kirov
- Bernard and Irene Schwartz Center for Biomedical Imaging, Center for Advanced Imaging Innovation and Research (CAI2R), Department of Radiology, New York University School of Medicine, New York, NY, USA
| | - Andrew A Maudsley
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Paul M Thompson
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, Los Angeles, CA, USA
- Departments of Neurology, Pediatrics, Psychiatry, Radiology, Engineering, and Ophthalmology, USC, Los Angeles, CA, USA
| | - Emily L Dennis
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, Los Angeles, CA, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- Psychiatry Neuroimaging Laboratory, Brigham & Women's Hospital, Boston, MA, USA
| | - David F Tate
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Elisabeth A Wilde
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Lin
- Center for Clinical Spectroscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Edwards GA, Maguire SA, Gaither JR, Leventhal JM. What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review. CHILD ABUSE REVIEW (CHICHESTER, ENGLAND : 1992) 2020; 29:253-268. [PMID: 37982093 PMCID: PMC10655946 DOI: 10.1002/car.2627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/26/2020] [Indexed: 11/21/2023]
Abstract
Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.
Collapse
Affiliation(s)
- George A Edwards
- Formerly of Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | | | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - John M Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
4
|
Wittschieber D, Karger B, Pfeiffer H, Hahnemann ML. Understanding Subdural Collections in Pediatric Abusive Head Trauma. AJNR Am J Neuroradiol 2018; 40:388-395. [PMID: 30523144 DOI: 10.3174/ajnr.a5855] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [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.
Collapse
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
| |
Collapse
|
5
|
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: 181] [Impact Index Per Article: 30.2] [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.
Collapse
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
| |
Collapse
|
6
|
Cowley LE, Maguire S, Farewell DM, Quinn-Scoggins HD, Flynn MO, Kemp AM. Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: A qualitative study. CHILD ABUSE & NEGLECT 2018; 82:178-191. [PMID: 29913434 DOI: 10.1016/j.chiabu.2018.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/07/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: 'professional', 'medical', 'circumstantial', 'family', 'psychological' and 'legal' factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants' experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency.
Collapse
Affiliation(s)
- Laura E Cowley
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
| | - Sabine Maguire
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
| | - Daniel M Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
| | | | - Matthew O Flynn
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
| | - Alison M Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
| |
Collapse
|
7
|
Cooper MT, Szyld E, Darden PM. Abusive head trauma in Spanish language medical literature. CHILD ABUSE & NEGLECT 2016; 58:173-179. [PMID: 27434224 DOI: 10.1016/j.chiabu.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 06/21/2016] [Accepted: 07/01/2016] [Indexed: 06/06/2023]
Abstract
Anecdotal experiences raise concerns that abusive head trauma (AHT) is significantly underdiagnosed and perhaps poorly recognized in Latin American settings. With increasing interest in international collaboration in pediatrics, differences in perspectives regarding complex diagnoses should be explored to facilitate a productive exchange of knowledge and ideas. The purpose of this study was to describe the medical literature pertaining to AHT available to physicians who read only in Spanish. In this review, LILACS, SciELO (major Spanish language databases) and Pubmed were searched with appropriate terms and filters in English, Spanish, and Portuguese for Spanish language articles on AHT. Identified articles' reference lists were then examined for possible additional articles on AHT. All relevant articles were sorted by country and examined for article type and content. Thirty-four unique articles were located for review from 8 of 21 countries. Most of the articles identified were case reports, case series, or educational, and there were no studies regarding overall incidence or prevalence of AHT. Some scientific information contained in the articles varied considerably from that in the English language literature in the areas of etiology and preventive strategies. This survey highlights that the Spanish language literature regarding AHT is sparse and variable. This must be considered when working collaboratively in a global setting. Additionally, identification of this gap presents an opportunity for education and information exchange among global medical communities.
Collapse
Affiliation(s)
- M Townsend Cooper
- The University of Oklahoma Health Sciences Center, Department of Pediatrics, General and Community Pediatrics, 1200 Children's Ave, Suite 12400, Oklahoma City, OK 73104, USA.
| | - Edgardo Szyld
- The University of Oklahoma Health Sciences Center, Department of Pediatrics, Neonatal-Perinatal Medicine, 1200 Everett Drive, ETNP7504, Oklahoma City, OK 73104, USA.
| | - Paul M Darden
- The University of Oklahoma Health Sciences Center, Department of Pediatrics, General and Community Pediatrics, 1200 Children's Ave, Suite 12400, Oklahoma City, OK 73104, USA.
| |
Collapse
|
8
|
Leeuw MD, Beuls E, Jorens PG, Parizel P, Jacobs W. The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse. J Forensic Leg Med 2015; 36:43-8. [PMID: 26386200 DOI: 10.1016/j.jflm.2015.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 05/12/2015] [Accepted: 08/24/2015] [Indexed: 11/27/2022]
Abstract
In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.
Collapse
Affiliation(s)
- Marc De Leeuw
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium; Community Hospital Aalst, Merestraat 80, B-9300 Aalst, Belgium; Decanaat University of Gent, De pintelaan, 185, 9000 Gent, Belgium
| | - Emile Beuls
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
| | - Philippe G Jorens
- Department of Intensive Care Medicine, Antwerp University Hospital, University of Antwerp Wilrijkstraat 10, B-2650 Edegem, Belgium
| | - Paul Parizel
- Department of Radiology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
| | - Werner Jacobs
- Department of Forensic Medicine and Pathology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
| |
Collapse
|
9
|
Abstract
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Collapse
|
10
|
Wittschieber D, Karger B, Niederstadt T, Pfeiffer H, Hahnemann ML. Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications. AJNR Am J Neuroradiol 2015; 36:432-9. [PMID: 24948499 PMCID: PMC8013070 DOI: 10.3174/ajnr.a3989] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan.
Collapse
Affiliation(s)
- D Wittschieber
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - B Karger
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - T Niederstadt
- Clinical Radiology (T.N.), University Hospital Münster, Münster, Germany
| | - H Pfeiffer
- From the Departments of Forensic Medicine (D.W., B.K., H.P.)
| | - M L Hahnemann
- Department of Diagnostic and Interventional Radiology and Neuroradiology (M.L.H.), University Hospital Essen, Essen, Germany
| |
Collapse
|
11
|
Ann Sens M, Meyers SE, Koponen MA, Graff AH, Reynolds RD, Storm WG. Cervical Ganglia and Nerve Root Injury: Evidence for Respiratory Arrest as Initiating Injury in Pediatric Head Trauma. Acad Forensic Pathol 2014. [DOI: 10.23907/2014.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mary Ann Sens
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Sarah E. Meyers
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Mark A. Koponen
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Arne H. Graff
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Ryan D. Reynolds
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| | - Waldemar G. Storm
- Professor and Chair of Pathology at University of North Dakota School of Medicine and Health Sciences, Coroner, Grand Forks County, ND, Forensic Examiner for 19 counties in ND, and Chief Medical Examiner for Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Polk, Red Lake and Roseau Counties in MN
| |
Collapse
|
12
|
Fatal pediatric head injuries: a 20-year review of cases through the Auckland coroner's office. Am J Forensic Med Pathol 2014; 34:277-82. [PMID: 23949141 DOI: 10.1097/paf.0b013e3182a187e9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inflicted pediatric head injury is a significant issue in New Zealand, fatal cases receiving extensive media attention. The primary aims of this article were to analyze injury patterns and reported mechanisms against both age and cause (accidental or inflicted). The secondary aims were to quantify these deaths and identify trends over time. We retrospectively reviewed pediatric deaths due to head injury in children younger than 15 years referred to the Coronial Service of Auckland, New Zealand, from January 1, 1991, to December 31, 2010. One hundred sixty-seven cases were identified. Overall incidence was stable over time; however, the rate of inflicted head injury increased significantly (from 0.1 to 0.4/100,000 per year). Evidence of impact was seen in 90% of cases. In children younger than 2 years, in the absence of motor vehicle or pedestrian trauma, subdural hemorrhage and diffuse axonal injury were both highly suggestive of inflicted injury. The absence of a history of trauma or a history of a fall less than 1 m was also highly suggestive of inflicted injury. Retinal hemorrhages in these fatal head injuries were severe in 77% of cases and moderate in the remainder.
Collapse
|
13
|
Holmgren BK. Ethical Issues in Forensic Testimony Involving Abusive Head Trauma. Acad Forensic Pathol 2013. [DOI: 10.23907/2013.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Medical examiners provide critical diagnostic and testimonial information in abusive head trauma cases. Courtroom challenges to these diagnostic criteria and contested expert testimony have raised concerns about ethical and professional conduct of practitioners. Legal evidentiary standards for expert testimony, ethical guidelines established by medical organizations, and proposed standards for ethical practice provide a background for examination of several common challenges and testimonial claims in these cases.
Collapse
|
14
|
Patterns of structural head injury in children younger than 3 years: a ten-year review of 519 patients. J Trauma Acute Care Surg 2013; 74:276-81. [PMID: 23147184 DOI: 10.1097/ta.0b013e318270d82e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abusive head injury is a major contributor to morbidity and mortality in infants and toddlers, but data comparing patterns of injury in corroborated accidental trauma and confessed child abuse are scarce. METHODS This is a retrospective review of head injuries with abnormal neuroimaging in children younger than 3 years during a 10-year period in Auckland, New Zealand. Histories were assumed to be true. Results were analyzed for incongruity then compared with data on confessed abuse and corroborated accidental injury. RESULTS Five hundred nineteen cases were analyzed. Most cases were congruent with the history, and their pattern was consistent with the literature on accidental head trauma in childhood. However, a spike of subdural hemorrhage was seen in the first 6 months of life, explained neither by mechanism nor by published data on birth trauma. The age distribution of retinal hemorrhage was also inconsistent with published data on birth trauma. In infants younger than 6 months, retinal and subdural hemorrhages were associated with the absence of a history of trauma. In older children (6 months-3 years), subdural hemorrhage was more common after minor falls (<1 m, 49%) than major falls (>2 m, 20%) (p = 0.002). CONCLUSION We conclude that when a young child (particularly an infant younger than 6 months) presents with traumatic intracranial pathology and either no history of trauma or a history of a minor fall, it must be seriously considered that the history is false. LEVEL OF EVIDENCE Epidemiologic study, level III.
Collapse
|
15
|
A Review of Blunt Force Injury Homicides of Children Aged 0 to 5 Years in Bexar County, Texas, From 1988 to 2009. Am J Forensic Med Pathol 2012; 33:344-8. [DOI: 10.1097/paf.0b013e31821a88c4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Laurent-Vannier A, Nathanson M, Quiriau F, Briand-Huchet E, Cook J, Billette de Villemeur T, Chazal J, Christophe C, Defoort-Dhellemmes S, Fortin G, Rambaud C, Raul JS, Rey-Salmon C, Sottet F, Vieux E, Vinchon M, Willinger R. A public hearing. "Shaken baby syndrome: guidelines on establishing a robust diagnosis and the procedures to be adopted by healthcare and social services staff". Scoping report. Ann Phys Rehabil Med 2011; 54:533-99. [PMID: 22118913 DOI: 10.1016/j.rehab.2011.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Laurent-Vannier
- Service de rééducation des pathologies neurologiques acquises de l'enfant, hôpitaux de Saint-Maurice, 14, rue du Val-d'Osne, 94415 Saint-Maurice cedex, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Matshes EW, Evans RM, Pinckard JK, Joseph JT, Lew EO. Shaken Infants Die of Neck Trauma, Not of Brain Trauma. Acad Forensic Pathol 2011. [DOI: 10.23907/2011.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Shaken baby syndrome (SBS) is routinely diagnosed on the basis of a classic triad of autopsy findings, namely retinal hemorrhage, subdural hemorrhage, and anoxic encephalopathy. However, ongoing controversy exists regarding the specificity and potential causes of these signs, and hence their reliability as de facto markers of SBS, or of non-accidental head injury, where no external signs of trauma are evident. We investigated the deaths of 35 infants and young children, which fell into two broad groups: those with suspected hyperflexion/extension neck injuries, and those without. At autopsy, the entire cervical spinal column (spinal cord, vertebrae, intervertebral discs, neurovascular structures and adjacent soft tissues) was removed, formalin-fixed, decalcified, dissected, and microscopically evaluated. Of the 12 cases in which hyperflexion/extension was either suspected or confirmed, all had evidence of either bilateral or unilateral hemorrhages within or surrounding the C3, C4, and/or C5 cervical spinal nerve roots. We provide evidence that hyperflexion/extension forces as experienced by shaken and impacted infants and young children lead to injury of the cervical spinal nerve roots that innervate the diaphragm, with resulting asphyxia and hypoxic brain injury. Therefore, we propose that trauma to the third through fifth cervical spinal nerve roots induced by hyperflexion/extension of the neck is the cause of the anoxic encephalopathy of the classic SBS triad, and is therefore not only a more specific indicator of hyperflexion/extension injury than subdural hemorrhage alone, but is the mechanism of injury in these cases.
Collapse
Affiliation(s)
- Evan W. Matshes
- Province of Alberta (Calgary, Canada)
- Academic Forensic Pathology Incorporated, Calgary, AB (RE), Southwestern Institute of Forensic Sciences, Dallas, TX (KP), University of Calgary and Calgary Laboratory Services - Division of Neuropathology, Calgary, Alberta (JJ), Miami-Dade County Medical Examiner Department, Miami, FL (EL)
| | - Rhian M. Evans
- Academic Forensic Pathology Incorporated, Calgary, AB (RE), Southwestern Institute of Forensic Sciences, Dallas, TX (KP), University of Calgary and Calgary Laboratory Services - Division of Neuropathology, Calgary, Alberta (JJ), Miami-Dade County Medical Examiner Department, Miami, FL (EL)
| | - J. Keith Pinckard
- Academic Forensic Pathology Incorporated, Calgary, AB (RE), Southwestern Institute of Forensic Sciences, Dallas, TX (KP), University of Calgary and Calgary Laboratory Services - Division of Neuropathology, Calgary, Alberta (JJ), Miami-Dade County Medical Examiner Department, Miami, FL (EL)
| | - Jeffrey T. Joseph
- Academic Forensic Pathology Incorporated, Calgary, AB (RE), Southwestern Institute of Forensic Sciences, Dallas, TX (KP), University of Calgary and Calgary Laboratory Services - Division of Neuropathology, Calgary, Alberta (JJ), Miami-Dade County Medical Examiner Department, Miami, FL (EL)
| | - Emma O. Lew
- Academic Forensic Pathology Incorporated, Calgary, AB (RE), Southwestern Institute of Forensic Sciences, Dallas, TX (KP), University of Calgary and Calgary Laboratory Services - Division of Neuropathology, Calgary, Alberta (JJ), Miami-Dade County Medical Examiner Department, Miami, FL (EL)
| |
Collapse
|
18
|
Esernio-Jenssen D, Tai J, Kodsi S. Abusive head trauma in children: a comparison of male and female perpetrators. Pediatrics 2011; 127:649-57. [PMID: 21382943 DOI: 10.1542/peds.2010-1770] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the effect of perpetrator gender on victim presentation and outcomes, and perpetrator legal outcomes for abusive head trauma (AHT). METHODS We performed a retrospective chart review of AHT cases from 1998 to 2008. Patient clinical data and information regarding perpetrator legal outcome was obtained. Relationship of brain injury and retinal hemorrhages (RHs) and differences in categorical variables of perpetrator gender were compared by using Fisher's exact test. Differences in continuous variables between perpetrator gender were compared by using the Mann-Whitney Test. RESULTS There were 34 cases of AHT with identified perpetrators, 17 of each gender. Mean age of the victims was 9.4 months (SD: 7.8). Thirty-two (94%) had intracranial hemorrhages, 14 (41%) had both primary and secondary brain injury, 28 (82%) had RHs, and 6 (18%) died. The severity of RH was related to the severity of brain injuries (P = .01). The median age for female perpetrators (34 years) was higher than that for males (27 years; P = .001). Six categorical variables were associated with male perpetrator gender: acute presenting symptoms of cardiopulmonary or respiratory arrest (P = .025), worse clinical outcome (P = .012), neurosurgical intervention (P = .037), death (P = .018), perpetrator confession (P = .0001), and conviction (P = .005). CONCLUSIONS There were significant perpetrator gender differences of AHT in children. Male perpetrators were younger and more likely to confess and be convicted. Victims of male perpetrators had more serious acute presentations and neurosurgical intervention and suffered worse clinical outcomes.
Collapse
Affiliation(s)
- Debra Esernio-Jenssen
- Department of Pediatrics, University of Florida, 1701-A SW 16th Ave, Gainesville, FL 32608, USA.
| | | | | |
Collapse
|
19
|
Su E, Bell MJ, Wisniewski SR, Adelson PD, Janesko-Feldman KL, Salonia R, Clark RSB, Kochanek PM, Kagan VE, Bayır H. α-Synuclein levels are elevated in cerebrospinal fluid following traumatic brain injury in infants and children: the effect of therapeutic hypothermia. Dev Neurosci 2010; 32:385-95. [PMID: 21124000 DOI: 10.1159/000321342] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 09/15/2010] [Indexed: 01/02/2023] Open
Abstract
α-Synuclein is one of the most abundant proteins in presynaptic terminals. Normal expression of α-synuclein is essential for neuronal survival and it prevents the initiation of apoptosis in neurons through covalent cross-linking of cytochrome c released from mitochondria. Exocytosis of α-synuclein occurs with neuronal mitochondrial dysfunction, making its detection in cerebrospinal fluid (CSF) of children after severe traumatic brain injury (TBI) a potentially important marker of injury. Experimental therapeutic hypothermia (TH) improves mitochondrial function and attenuates cell death, and therefore may also affect CSF α-synuclein concentrations. We assessed α-synuclein levels in CSF of 47 infants and children with severe TBI using a commercial ELISA for detection of monomeric protein. 23 patients were randomized to TH based on published protocols where cooling (32-33°C) was initiated within 6-24 h, maintained for 48 h, and then followed by slow rewarming. CSF samples were obtained continuously via an intraventricular catheter for 6 days after TBI. Control CSF (n = 9) was sampled from children receiving lumbar puncture for CSF analysis of infection that was proven negative. Associations of initial Glasgow Coma Scale (GCS) score, age, gender, treatment, mechanism of injury and Glasgow Outcome Scale (GOS) score with CSF α-synuclein were compared by multivariate regression analysis. CSF α-synuclein levels were elevated in TBI patients compared to controls (p = 0.0093), with a temporal profile showing an early, approximately 5-fold increase on days 1-3 followed by a delayed, >10-fold increase on days 4-6 versus control. α-Synuclein levels were higher in patients treated with normothermia versus hypothermia (p = 0.0033), in patients aged <4 years versus ≥4 years (p < 0.0001), in females versus males (p = 0.0007), in nonaccidental TBI versus accidental TBI victims (p = 0.0003), and in patients with global versus focal injury on computed tomography of the brain (p = 0.046). Comparisons of CSF α-synuclein levels with initial GCS and GOS scores were not statistically significant. Further studies are needed to evaluate the conformational status of α-synuclein in CSF, and whether TH affects α-synuclein aggregation.
Collapse
Affiliation(s)
- Erik Su
- Safar Center for Resuscitation Research, Pittsburgh, PA 15260, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Colbert CA, Holshouser BA, Aaen GS, Sheridan C, Oyoyo U, Kido D, Ashwal S. Value of Cerebral Microhemorrhages Detected with Susceptibility-weighted MR Imaging for Prediction of Long-term Outcome in Children with Nonaccidental Trauma. Radiology 2010; 256:898-905. [DOI: 10.1148/radiol.10091842] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
21
|
Ilves P, Lintrop M, Talvik I, Sisko A, Talvik T. Predictive value of clinical and radiological findings in inflicted traumatic brain injury. Acta Paediatr 2010; 99:1329-36. [PMID: 20377537 DOI: 10.1111/j.1651-2227.2010.01820.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study is to evaluate the value of early radiological investigations in predicting the long-term neurodevelopmental outcome of infants with inflicted traumatic brain injury (ITBI). METHODS Clinical and radiological investigations of 24 infants with ITBI were performed during the acute phase of injury (1-3 days), and during the early (4 days up to 3 months) and late (>9 months) postinjury phases. The clinical outcome in survivors (n = 22) was based on the Rankin Disability Scale and the Glasgow Outcome Score. RESULTS Five out of 24 infants (21%) had a poor neurodevelopmental outcome (death and severe disability), 17 infants (71%) had different developmental problems and 2 infants were normal at the mean age of 62 (54-70) (95% CI) months. A low initial Glasgow Coma Scale score of 8 or below [p < 0.05, OR 13.0 (1.3-133.3)], the development of brain oedema [p < 0.005, OR 13.0 (1.6-773)], focal changes in the basal ganglia during the acute phase [p < 0.01, OR 45 (2.1-937.3)], the development of new intracerebral focal changes early postinjury [p < 0.05, OR 24.1(1.0-559.1)], a decrease in white matter [p < 0.01, OR 33 (1.37-793.4)] and the development of severe atrophy before 3 months postinjury [p < 0.05, OR 24 (11.0-559.1)] were significantly correlated with a poor neurodevelopmental outcome. CONCLUSIONS Early clinical and radiological findings in ITBI are of prognostic value for neurodevelopmental outcome.
Collapse
Affiliation(s)
- Pilvi Ilves
- Radiology Clinic, Tartu University Hospital, Tartu, Estonia.
| | | | | | | | | |
Collapse
|
22
|
Aaen GS, Holshouser BA, Sheridan C, Colbert C, McKenney M, Kido D, Ashwal S. Magnetic resonance spectroscopy predicts outcomes for children with nonaccidental trauma. Pediatrics 2010; 125:295-303. [PMID: 20123781 DOI: 10.1542/peds.2008-3312] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We evaluated proton magnetic resonance spectroscopic imaging (MRSI) findings for children with traumatic brain injury attributable to nonaccidental trauma (NAT) early after injury, to determine whether brain metabolite changes predicted outcomes. METHODS Proton MRSI (1.5 T) was performed (mean: 5 days after injury [range: 1-30 days]) through the level of the corpus callosum for 90 children with confirmed NAT. Regional N-acetylaspartate/total creatine, N-acetylaspartate/total choline, and choline/creatine ratios and the presence of lactate were measured. Data on long-term outcomes defined at > or =6 months were collected for 44 of 90 infants. We grouped patients into good (normal, mild disability, or moderate disability; n = 32) and poor (severe disability, vegetative state, or dead; n = 12) outcome groups. RESULTS We found that N-acetylaspartate/creatine and N-acetylaspartate/choline ratios (mean total, corpus callosum, and frontal white matter) were significantly decreased in patients with poor outcomes (P < .001). A logistic regression model using age, initial Glasgow Coma Scale score, presence of retinal hemorrhage, lactate on MRSI scans, and mean total N-acetylaspartate/creatine ratio predicted outcomes accurately in 100% of cases. CONCLUSIONS Reduced N-acetylaspartate levels (ie, neuronal loss/dysfunction) and elevated lactate levels (altered energy metabolism) correlated with poor neurologic outcomes for infants with NAT. Elevated lactate levels may reflect primary or secondary hypoxic-ischemic injury, which may occur with NAT. Our data suggest that MRSI performed early after injury can be used for long-term prognosis.
Collapse
Affiliation(s)
- Gregory S Aaen
- Loma Linda University School of Medicine, Department of Pediatrics, 11175 Campus St, Room A1120, Loma Linda, CA 92354, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head injury?--yes. Eye (Lond) 2009; 23:1758-60. [PMID: 19662083 DOI: 10.1038/eye.2009.199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|