Imaging of Abusive Head Trauma: A Review and Update

Suspected abusive head trauma in children - when do they really need to be transferred to a neurosurgical unit?

OBJECTIVES

Transferring paediatric patients with suspected abusive head trauma (AHT) to paediatric neurosurgical centres, disrupts safeguarding investigations. Therefore, it is desirable that suspected AHTs are transferred only when clinically necessary. The aim of this study was to describe referral patterns of patients referred to a tertiary paediatric neurosurgical centre with suspected AHT, with the view of informing future transfer of AHT patients.

DESIGN

A retrospective review was performed of all suspected AHT patients referred to the University Hospital of Wales between 2012 and 2021.

METHODS

Rates of surgery, intubation and ventilation, radiological findings and presenting GCS were compared between referred patients and those transferred for neurosurgical care. Variables were compared between the transferred and the non-transferred groups. For categorical variables, Chi-squared tests were performed, with Fisher's exact test used where the expected count was less than 5. Odds ratios (OR) for neurosurgical transfer with radiological or clinical features at presentation were calculated.

RESULTS

A total of 76 patients were referred, of which 18 were transferred for neurosurgical care. Of these, six were intubated and ventilated. Only one transferred patient required surgery, with the remainder receiving supportive care. Amongst the transferred group, 77.8% had SDHs and 68.6% had a GCS ≥ 13 at presentation. Patients with a GCS ≥ 13 and SDHs, bilateral haematomas or a history of vomiting were significantly more likely to be transferred (OR = 4.27, 95%CI 1.01-18.00, p = .05).

CONCLUSIONS

Most transferred patients with suspected AHT did not receive surgical intervention. We suggest that patients should be transferred when it is likely that they will require surgery, otherwise they should stay locally in order to complete their safeguarding investigations. Immediate transfer may not be necessary for AHT patients with a GCS ≥ 13 and either vomiting, SDHs or bilateral haematomas, provided they are unlikely to require emergency surgery.

Abusive head trauma in children: radiographs of the skull do not provide additional information in the diagnosis of skull fracture when multiplanar computed tomography with three-dimensional reconstructions is available

BACKGROUND

Some data suggest that CT is more accurate than skull radiographs in diagnosing skull fractures in abusive head trauma.

OBJECTIVES

We investigated whether multiplanar CT with three-dimensional (3-D) reconstructions alone is non-inferior to combination CT/skull radiography for the diagnosis of skull fracture in suspected physical abuse.

MATERIALS AND METHODS

We identified children who had skull radiographs and concurrent multiplanar CT with 3-D reconstructions obtained during suspected physical abuse imaging between 2010 and 2019, and a fracture diagnosis in the formal report. We included all fracture cases and an equal number of randomly selected non-fracture controls in an anonymised dataset. This dataset was independently reviewed for skull fracture by two paediatric radiologists and one less-experienced trainee using either radiography alone, CT alone or CT/skull radiography. The primary outcome was discordance in diagnosis of skull fracture between CT alone and CT/skull radiography, with a result > 0.03 deemed to indicate inferiority of CT alone. The Fleiss kappa was used to assess interobserver agreement.

RESULTS

We included 106 children, 53 with and 53 without skull fracture. A single case was discordant between CT alone and CT/skull radiography, resulting in discordance of 0.009, consistent with non-inferiority of CT alone. The sensitivity and specificity of CT alone and CT/skull radiography were 98% and 96-98%, respectively, whereas radiography alone was more inaccurate (81% sensitivity and 96% specificity). Interobserver agreement for all modalities was very high (kappa 0.86-0.95).

CONCLUSION

Multiplanar CT with 3-D reconstructions alone is not inferior (and clinically equivalent) to CT/skull radiography for diagnosing skull fracture in suspected physical abuse imaging and was as accurate when reported by a less-experienced trainee. This suggests that skull radiography can be removed from suspected physical abuse imaging guidelines.