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Kelly JP, Feldman KW, Weiss A. OPTICAL COHERENCE TOMOGRAPHY AND VISUAL OUTCOMES IN PEDIATRIC ABUSIVE HEAD TRAUMA. Retin Cases Brief Rep 2024; 18:225-229. [PMID: 36121805 DOI: 10.1097/icb.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Compare follow-up optical coherence tomography with visual function in children with abusive head trauma (shaken baby syndrome). METHODS Retrospective follow-up studies of three children who were victims of abusive head trauma within the first year of life. RESULTS Optical coherence tomography showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in three of four eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual-evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage. CONCLUSION Significant abnormalities of retinal anatomy can be detected on optical coherence tomography years after abusive head trauma. Optical coherence tomographies and assessment of visual pathways help to elucidate causes of visual dysfunction in children with abusive head trauma.
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Affiliation(s)
- John P Kelly
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, Seattle, Washington
- Department of Ophthalmology, University of Washington
| | - Kenneth W Feldman
- Seattle Children's Hospital, Safe Child and Adolescent Network, Seattle, Washington; and
- University of Washington, Division of General Pediatrics, Seattle, Washington
| | - Avery Weiss
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, Seattle, Washington
- Department of Ophthalmology, University of Washington
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2
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Sokoloff M, Feldman KW, Levin AV, Rockter A, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Hymel KP. Retinal hemorrhage variation in inertial versus contact head injuries. CHILD ABUSE & NEGLECT 2024; 149:106606. [PMID: 38134727 DOI: 10.1016/j.chiabu.2023.106606] [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: 07/23/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. OBJECTIVE The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. PARTICIPANTS AND SETTING This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. METHODS Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. RESULTS PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91-170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004-0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09-67.01) vs 0.5 % (2/339), OR = 0.04 (0.01-0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. CONCLUSIONS cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries.
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Affiliation(s)
- Michael Sokoloff
- Department of Pediatrics, Pediatric Intensive Care, Sacred Heart Children's Hospital, Spokane, WA, United States of America.
| | - Kenneth W Feldman
- Department of Pediatrics, Seattle Children's, University of Washington's Harborview Medical Center, Seattle, WA, United States of America; Department of Pediatrics, Safe Child and Adolescent Network, Seattle Children's, Seattle, WA, United States of America.
| | - Alex V Levin
- Department of Ophthalmology, Flaum Eye Institute, University of Rochester, Rochester, NY, United States of America.
| | - Adam Rockter
- University of Rochester School of Medicine, Rochester, NY, United States of America.
| | - Veronica Armijo-Garcia
- Department of Pediatrics, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, United States of America.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States of America.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, KS, United States of America.
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA, United States of America.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States of America.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, United States of America.
| | - Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, United States of America
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Dasgupta D, Elhusseiny AM, Phillips PH, Jayappa S, Hill SEM, Tanaka T, Glasier CM, Vilanilam GK, Purushothaman R, Clingenpeel R, Murray L, Choudhary A, Ramakrishnaiah R. Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma. Pediatr Radiol 2023; 53:1842-1853. [PMID: 37079040 DOI: 10.1007/s00247-023-05614-9] [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: 10/07/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 04/21/2023]
Abstract
Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.
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Affiliation(s)
- Dhruba Dasgupta
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | | | - Paul H Phillips
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Sateesh Jayappa
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | | | - Tomoko Tanaka
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Charles M Glasier
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - George Koshy Vilanilam
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Rangarajan Purushothaman
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Rachel Clingenpeel
- Department of Pediatrics, University of Arkansas for Medical Sciences, Clark Center, 1210 Wolfe St., Mail Slot # 512-24A, Little Rock, AR, 72202, USA
| | - Liza Murray
- Department of Pediatrics, University of Arkansas for Medical Sciences, Clark Center, 1210 Wolfe St., Mail Slot # 512-24A, Little Rock, AR, 72202, USA
| | - Arabinda Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Raghu Ramakrishnaiah
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [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: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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Macher J, Porter RS, Levin AV. Ophthalmic imaging in abusive head trauma. CHILD ABUSE & NEGLECT 2023; 139:106106. [PMID: 36867971 DOI: 10.1016/j.chiabu.2023.106106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Ophthalmic imaging plays an increasingly important role the evaluation of abusive head trauma, however these imaging modalities may be unfamiliar to non-ophthalmologists. OBJECTIVE To provide pediatricians and child abuse pediatric professionals with background on ophthalmic imaging techniques in the context of suspected abuse, as well as information on commercial options and costs for those interested in augmenting their ophthalmic imaging capabilities. METHODS We performed a review of the ophthalmic imaging literature for fundus photography, ocular coherence tomography, fluorescein angiography, ocular ultrasound, computed tomography, magnetic resonance imaging and postmortem imaging. We also contacted individual vendors for equipment pricing information. RESULTS For each ophthalmic imaging modality, we demonstrate its role in the evaluation of abusive head trauma including indications, potential findings, sensitivity and specificity of findings for abuse, and commercial options. CONCLUSIONS Ophthalmic imaging is an important supportive component of the evaluation for abusive head trauma. When used in conjunction with clinical examination, ophthalmic imaging can improve diagnostic accuracy, support documentation, and possibly improve communication in medicolegal contexts.
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Affiliation(s)
- Jared Macher
- University of Rochester School of Medicine, Rochester, NY, USA.
| | - Randall S Porter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Alex V Levin
- University of Rochester School of Medicine, Rochester, NY, USA; Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Rochester, NY, USA; Clinical Genetics, Golisano Children's Hospital, Rochester, NY, USA.
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Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to retinal hemorrhages. Doc Ophthalmol 2023:10.1007/s10633-023-09927-w. [PMID: 36881212 DOI: 10.1007/s10633-023-09927-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/06/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures. METHODS Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR). RESULTS Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping. DISCUSSION Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.
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7
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Simon CL, Ude I, Levin MR, Alexander JL. Retinal hemorrhages in abusive head trauma with atraumatic neuroimaging. J AAPOS 2023; 27:39-42. [PMID: 36516943 PMCID: PMC9975066 DOI: 10.1016/j.jaapos.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022]
Abstract
We report 3 cases of suspected abusive head trauma with retinal hemorrhages on fundus examination and neuroimaging findings not necessarily suggestive of shaking injury. Previous studies have suggested that retinal hemorrhages are rare in patients without neuroimaging abnormalities. These cases demonstrate some common features (rib fractures, developmental delay, and history of abuse) that may increase suspicion for abusive head trauma. Our findings suggest a potential role for ophthalmic consultation in scenarios with high clinical suspicion for abusive head trauma without definitive neuroimaging evidence of head injury. The nonspecific neuroimaging features of these 3 cases highlight the importance of interpreting cases with global clinical context.
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Affiliation(s)
| | - Ifeoma Ude
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Moran R Levin
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet L Alexander
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland.
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8
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Harris CK, Stagner AM. The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma? Semin Ophthalmol 2023; 38:3-8. [PMID: 36524752 DOI: 10.1080/08820538.2022.2152712] [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] [Indexed: 12/23/2022]
Abstract
Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Anna M Stagner
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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9
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Christian CW, Binenbaum G. The eye in child abuse. Childs Nerv Syst 2022; 38:2335-2344. [PMID: 35871261 DOI: 10.1007/s00381-022-05610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.
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Affiliation(s)
- Cindy W Christian
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA.
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Ophthalmology, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA
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Su M, Taylor K, Stoutin J, Shaver C, Recko M. Evidence-Based Screening to Optimize the Yield of Positive Ophthalmologic Examinations in Children Evaluated for Suspected Child Abuse. J Pediatr Ophthalmol Strabismus 2022; 59:310-319. [PMID: 35446193 DOI: 10.3928/01913913-20220216-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine nonocular findings associated with significant retinal hemorrhage on dilated fundus examination in cases of suspected child abuse. METHODS This was a retrospective chart review from May 2014 to August 2021 at a level-1 trauma center. Two hundred seventy-four patients met the following inclusion criteria: (1) children 36 months and younger; (2) concern for child abuse; and (3) had an ophthalmology consultation. Through univariate and multivariate logistic regression, the study produced a screening algorithm for ophthalmic work-up in child abuse. RESULTS One or more abnormal neuroimaging findings had a statistically significant association with retinal hemorrhages and produced the strongest association with a univariate odds ratio of 170 (confidence interval: 10.245 to > 999.999). The multivariate model (P < .0001 with a c-statistic of 0.980) proposes using the following variables for predicting retinal hemorrhage on examination: abnormal neuroimaging, Glasgow Coma Scale score less than 15, altered mental status on examination, seizure activity, vomiting, bruising, scalp hematoma/swelling, and skull fractures. CONCLUSIONS This study elucidates clinical and imaging factors that correlate to retinal findings, validating previously studied variables and introducing new variables to be considered. The authors propose an evidence-based screening algorithm to increase the yield of positive dilated examinations and decrease the burden of potentially unnecessary child abuse ophthalmologic examinations. [J Pediatr Ophthalmol Strabismus. 2022;59(5):310-319.].
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Chung CW, Levin AV, Forbes BJ, Binenbaum G. Retinal hemorrhage after pediatric neurosurgical procedures. J AAPOS 2022; 26:74.e1-74.e5. [PMID: 35304320 DOI: 10.1016/j.jaapos.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neurosurgical procedures may occur prior to eye examination in children with suspected abusive head trauma and raise questions by child abuse physicians and ophthalmologists regarding the contribution of neurosurgery to retinal hemorrhage found postoperatively. The purpose of this study was to determine the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention in children. METHODS We conducted a retrospective cohort study of children undergoing neurosurgery who had postoperative ophthalmoscopy. Some children were also examined preoperatively. Primary outcome measures were the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention. Medical records were reviewed to identify confounding coexistent diseases. RESULTS Among 267 children undergoing 289 neurosurgical procedures, there were no cases in which children had post-procedural retinal hemorrhage that could be attributed to neurosurgery. Retinal hemorrhage was seen in 32 (12%) cases, but in every case they were either already present on preoperative examination (13 cases) or matched the pattern of a coexistent known cause of retinal hemorrhage, including head trauma with unambiguous history and/or nonocular signs (13), hydrocephalus-related increased intracranial pressure with papilledema-associated peripapillary retinal hemorrhage (5), and retinopathy of prematurity ridge-associated retinal hemorrhage (1). No retinal hemorrhage could be attributed only to neurosurgery. CONCLUSIONS Although children undergoing child abuse evaluations may have intracranial hemorrhage requiring neurosurgery that occurs before a dilated retinal examination can be performed, our data suggest that neurosurgery independently is unlikely to produce retinal hemorrhage and therefore is not a significant confounding factor in the interpretation of retinal hemorrhage patterns in child abuse evaluations.
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Affiliation(s)
- Caroline W Chung
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V Levin
- Flaum Eye Institute and Golisano Children's Hospital, Rochester, New York
| | - Brian J Forbes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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12
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Moskwa R, Todeschi J, Wiedemann-Fode A, Stella I, Joud A, Klein O. Ophthalmological lesions in shaken baby syndrome: a retrospective analysis of 133 consecutive cases (1992-2018). Neurochirurgie 2022; 68:367-372. [PMID: 35150727 DOI: 10.1016/j.neuchi.2022.01.007] [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: 09/12/2020] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data. PATIENTS AND METHODS This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992 - 2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded. RESULTS Mean age at diagnosis was 131 days (range, 14 days - 10 months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6 months: 80%. CONCLUSION This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.
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Affiliation(s)
- Rémy Moskwa
- Department of Ophthalmology, Mercy Regional Hospital, Ars-Laquenexy, France; Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Julien Todeschi
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Arnaud Wiedemann-Fode
- Pediatric Intensive Care Unit, Children's Hospital, Nancy University Hospital, INSERM Unit 1256 N-GERE, Université de Lorraine, France
| | - Irene Stella
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Anthony Joud
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France
| | - Olivier Klein
- Service of Pediatric Neurosurgery, Children's Hospital, Nancy University Hospital, Université de Lorraine, France.
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Weiss R, He CH, Khan S, Parsikia A, Mbekeani JN. Ocular Injuries in Pediatric Patients Admitted With Abusive Head Trauma. Pediatr Neurol 2022; 127:11-18. [PMID: 34922138 DOI: 10.1016/j.pediatrneurol.2021.11.004] [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: 05/12/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT. METHODS This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed. RESULTS A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001). CONCLUSIONS AND RELEVANCE Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries.
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Affiliation(s)
- Rebecca Weiss
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | | | - Sabine Khan
- Department of Ophthalmology & Visual Sciences, Montefiore Medical Center, Bronx, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York; Research Services, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce N Mbekeani
- Albert Einstein College of Medicine, Bronx, New York; Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York.
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Oliva A, Grassi S, Cazzato F, Jabbehdari S, Mensi L, Amorelli G, Orazi L, Arena V, Lepore D. The role of retinal imaging in the management of abusive head trauma cases. Int J Legal Med 2022; 136:1009-1016. [DOI: 10.1007/s00414-021-02750-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
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Cho IH, Kim MS, Heo NH, Kim SY. Birth-related retinal hemorrhages: The Soonchunhyang University Cheonan Hospital universal newborn eye screening (SUCH-NES) study. PLoS One 2021; 16:e0259378. [PMID: 34752467 PMCID: PMC8577753 DOI: 10.1371/journal.pone.0259378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To report the prevalence, related factors, and characteristics of birth-related retinal hemorrhages (RHs) according to their severity in healthy newborns using a telemedicine network and wide-field digital retinal imaging (WFDRI). Methods Newborns who underwent WFDRI at 61 obstetrics/gynecology hospitals between January 2017 and December 2019 were enrolled. Demographics and related factors were compared among newborns with and without RHs. The newborns’ eyes were divided into the minimal, mild, moderate, and severe groups according to the number of RHs, and characteristics like bilaterality, laterality, involved retinal layer, involved zone, macular and/or optic nerve (ON) involvement were compared. Results Among 56247 newborns, 13026 had birth-related RHs (23.2%). Normal spontaneous vaginal delivery (NSVD) showed the highest association with RHs (odds ratio, 19.774; 95% confidence interval, 18.277–21.393; P < 0.001) on multivariate analysis. Bilateral RHs (8414/13026; 64.59%) were more common than unilateral RHs (4612/13026; 35.41%); however, unilateral RHs (2383/4217; 56.51%) were more common than bilateral RHs (1834/4217; 43.49%) in the minimal group. RHs showed no laterality differences between the two eyes (P = 0.493). Most RHs were intraretinal (18678/21440; 87.12%), and 2328 (31.65%) eyes with preretinal hemorrhage were observed in the severe group. Zone I RHs were common in the minimal (7072/7090; 99.75%), mild (4953/4960; 99.86%), and moderate (2013/2035; 98.92%) groups; zone I and II RHs were common in the severe group (4843/7355; 65.85%); and RHs in zone III were rare (7/21440; 0.03%). Most RHs showed no macular and/or ON involvement in the minimal and mild group; however, this was common in the severe group (7111/7355; 96.68%). Conclusions Birth-related RHs were common in healthy newborns and were significantly associated with NSVD. RHs were usually bilateral, intraretinal, and distributed posterior to the retina, but severe RHs had unique characteristics. Future long-term and longitudinal studies are required to elucidate the prognosis of severe RHs.
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Affiliation(s)
- In Hwan Cho
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Min Seong Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University, Cheonan, Korea
| | - So Young Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
- * E-mail:
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16
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Unusual eye injury related to abusive head trauma. Rechtsmedizin (Berl) 2021. [DOI: 10.1007/s00194-021-00460-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AbstractOphthalmological examination is an essential component in clinically diagnosing abusive head trauma (AHT). Typical of AHT injuries is retinal bleeding, with other parts of the eye sometimes also being affected. Visual impairment and blindness are long-term complications in this context. We present a case with unusual eye injuries after a diagnostically confirmed AHT.The ophthalmological findings on admission day showed a massive subhyaloid hemorrhage at the posterior pole and extensive flame-shaped intraretinal hemorrhages accented on the right side., A centrally localized vitreous hemorrhage appeared on both sides 3 weeks later, obscuring the optic disc and macula most probably due to a breakthrough of a sub-internal limiting membrane (ILM) hemorrhage into the vitreous cavity. Follow-up 4 weeks later revealed a dense and organized vitreous hemorrhage occupying the optic disc and macula so that a pars plana vitrectomy was performed on both eyes.The bilateral bleeding in different retinal layers, the vitreous hemorrhage and the proliferative vitreoretinal reaction (PVR) indicated massive damage caused by a significant acceleration-deceleration trauma. A two-phase vitreous hemorrhage in a child with AHT does not yet appear to have been described in the literature.
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Franchina M, Blaszkowska M, Lewis J, Johnson A, Clark A, Lam G, Mackey DA. Paediatric eye injuries during a COVID-19 pandemic lockdown. Clin Exp Optom 2021; 105:637-641. [PMID: 34402757 DOI: 10.1080/08164622.2021.1964921] [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: 12/09/2022] Open
Abstract
CLINICAL RELEVANCE Eye injuries, both accidental and non-accidental, are a significant cause of long-term visual impairment in children. An understanding of when and how such injuries occur is key to development of adequate prevention strategies. BACKGROUND To evaluate accidental and non-accidental eye injuries in children presenting to the major tertiary emergency department and outpatient ophthalmology clinic in Western Australia during the nationwide COVID-19 lockdown and to determine whether the frequency or nature of these injuries differed from pre-pandemic presentations. METHODS Retrospective review of the medical records of paediatric patients presenting to the emergency department and specialist ophthalmology clinic with an ocular injury and those presenting to the hospital Child Protection Unit with physical injuries during March-August 2020 and the same period in 2019. RESULTS There was no significant difference in the total number of accidental eye injury presentations during the lockdown period despite a significant decrease in emergency department attendance overall. Closed-globe injuries were the most common accidental eye injury presentation during lockdown (70/110, 64%), followed by adnexal injuries (39/110, 35%) and open-globe injuries (1/110, 1%). In contrast, referrals to the hospital Child Protection Unit for suspicious injuries declined during lockdown. Although eye injury presentations have changed in other parts of the world since the start of the pandemic, during COVID-19 lockdown in Western Australia, accidental paediatric ocular and adnexal trauma sustained at home continues to be a significant cause for hospital attendance. Public education regarding in-home eye injury prevention must be ongoing.
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Affiliation(s)
- Maria Franchina
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Magda Blaszkowska
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
| | - Joel Lewis
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Alice Johnson
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Antony Clark
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - Geoffrey Lam
- Department of Ophthalmology, Perth Children's Hospital, Nedlands, Australia
| | - David A Mackey
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Australia
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Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol 2021; 51:853-860. [PMID: 33999229 DOI: 10.1007/s00247-020-04864-1] [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: 06/01/2020] [Revised: 08/19/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022]
Abstract
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
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Affiliation(s)
- Colleen E Bennett
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Cindy W Christian
- Safe Place:The Center for Child Protection and Health, Division of General Pediatrics, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Zuccoli G. Magnetic resonance imaging of optic nerve and optic sheath hemorrhages in child abuse. Pediatr Radiol 2021; 51:997-1002. [PMID: 33999241 DOI: 10.1007/s00247-020-04891-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/23/2020] [Accepted: 10/19/2020] [Indexed: 11/25/2022]
Abstract
In abusive head trauma victims, optic nerves and optic sheath hemorrhages are commonly associated with retinal hemorrhages. Until now, optic nerve and optic nerve sheath hemorrhages related to abusive head trauma have been identified by exenteration and soft-tissue sectioning during postmortem examination. In 2013, we proposed the use of tailored high-resolution susceptibility-weighted imaging (SWI) MRI sequences to depict retinal hemorrhages in lieu of the gold standard dilated fundus exam, in select patients, and in 2017 we showed how the same high-resolution sequences used in the coronal plane can depict ruptured bridging veins in abusive head trauma. This paper describes the new potential diagnostic application of high-resolution axial and coronal SWI in the diagnosis of optic nerve and optic sheath hemorrhages.
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Affiliation(s)
- Giulio Zuccoli
- Program for the Study of Neurodevelopment in Rare Disorders (NDRD), UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA, 15224, USA.
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20
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Burge LR, Van Horne BS, Bachim A, Bhatt AR, Donaruma M. Timely recognition of retinal hemorrhage in pediatric abusive head trauma evaluation. J AAPOS 2021; 25:89.e1-89.e7. [PMID: 33865998 DOI: 10.1016/j.jaapos.2020.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/22/2020] [Accepted: 11/01/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Distinct patterns of retinal hemorrhages (RHs) are suggestive of abusive head trauma in the context of unexplained intracranial injury. Current recommendations encourage an eye examination within 48 hours of admission due to the rapid resolution of RH. The purpose of this study was to identify clinical factors associated with a delay in funduscopic examination outside the recommended 48 hours. METHODS Retrospective chart review was completed on all inpatient consultations by the Child Protection Team with evidence of intracranial injury on computed tomography or magnetic resonance imaging over 3 years at a large children's hospital. Extracted data included demographic characteristics, history of intubation, pediatric intensive care unit (PICU) admission, extraventricular drain placement, seizures, use of vasopressor support, and presence of other injuries. Descriptive statistics were used to describe the patient population, clinical characteristics, and outcomes. Multivariate logistic regression was used to identify factors associated with delayed eye examinations. RESULTS A total of 203 patients met inclusion criteria. Of those, 39 (19.2%) had a delay in initial funduscopic examination. Multivariate analyses revealed that PICU admission, surgical intervention, and seizure activity were significant predictors of delayed examination after controlling for multiple clinical factors. Neurosurgical consultation was shown to be protective against a delayed examination. CONCLUSIONS Rapid resolution of RH may occur in child abuse. Prompt ophthalmology examinations and neurosurgery consultation when child abuse is suspected help avoid a delay in diagnosis.
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Affiliation(s)
- Lauren R Burge
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Bethanie S Van Horne
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Angela Bachim
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Amit R Bhatt
- Department of Ophthalmology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Marcella Donaruma
- Department of Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Suh DW, Song HH, Mozafari H, Thoreson WB. Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma. Am J Ophthalmol 2021; 223:396-404. [PMID: 32663454 DOI: 10.1016/j.ajo.2020.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of infant death and long-term morbidity from injury. The ocular consequences of AHT are controversial, and the pathophysiology of retinal research findings is still not clearly understood. It has been postulated that vitreoretinal traction plays a major role in the retinal findings. A computer simulation model was developed to evaluate the vitreoretinal traction and determine whether the distribution of forces in different layers and locations of the retina can explain the patterns of retinal hemorrhage (RH) seen in AHT. DESIGN Computer simulation model study. METHODS A computer simulation model of the pediatric eye was developed to evaluate preretinal, intraretinal, and subretinal stresses during repetitive shaking. This model was also used to examine the forces applied to various segments along blood vessels. RESULTS Calculated stress values from the computer simulation ranged from 3-16 kPa at the vitreoretinal interface through a cycle of shaking. Maximal stress was observed at the periphery of the retina, corresponding to areas of multiple vessel bifurcations, followed by the posterior pole of the retina. Stress values were similar throughout all 3 layers of the retina (preretinal, intraretinal, and subretinal layers). CONCLUSIONS Ocular manifestations from AHT revealed unique retinal characteristics. The model predicted stress patterns consistent with the diffuse retinal hemorrhages (RH) typically found in the posterior pole and around the peripheral retina in AHT. This computer model demonstrated that similar stress forces were produced in different layers of the retina, consistent with the finding that retinal hemorrhages are often found in multiple layers of the retina. These data can help explain the RH patterns commonly found in AHT.
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Zuccoli G. Novel in vivo depiction of optic nerves hemorrhages in child abuse: a 3D-SWI pilot study. Neuroradiology 2021; 63:1113-1119. [PMID: 33471158 PMCID: PMC8213664 DOI: 10.1007/s00234-020-02622-6] [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: 11/03/2020] [Accepted: 12/08/2020] [Indexed: 12/04/2022]
Abstract
Purpose Until now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI. Methods Thirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected. Results The average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages. Conclusion This research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims.
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Affiliation(s)
- Giulio Zuccoli
- Consultant for the Program for the Study of Neurodevelopment in Rare Disorders (NDRD), University of Pittsburgh, Children Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
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Kozner P, Stepankova J, Dotrelova D. Long-term evaluation of pars plana vitrectomy in children with Abusive head trauma. Eur J Ophthalmol 2020; 32:553-558. [PMID: 33118379 DOI: 10.1177/1120672120968760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the efficacy of pars plana vitrectomy (PPV) in children with intraocular hemorrhage (IOH) secondary to Abusive head trauma (AHT). METHODS A long-term retrospective analysis evaluating epidemiology, management, safety, anatomical and functional results of PPV for IOH in children with AHT at tertiary referral center for children in the Czech Republic from 2004 to 2017. RESULTS 18 children were identified with IOH due to AHT during observation period of 14 years. Overall incidence of IOH related to AHT was 29.6/100 000, in children under 1 year 22.2/100 000, in children 1 to 5 years 7.4/100 000. Mean age at the time of diagnosis was 13.7 (SD±20.53) months, median 5 months. IOH resolved in 56% of children, 64% eyes, spontaneously. 44% children, 36% eyes, underwent PPV. PPV was performed 30.5 (SD±16.98) days after established diagnosis on average. Postoperatively, 80% of eyes had anatomical improvement, 20% eyes had preexisting irreversible changes in the posterior pole. Vision of 50% eyes improved after surgery, vision of 20% eyes remained poor, 30% of eyes was not possible to test due to severe neurological impairment. Mean observational period was 33.4 (SD±38.21) months. Mortality rate of AHT in our group was 17%, all victims were younger 4 months. CONCLUSIONS PPV is a safe and effective procedure to clear IOH in children with AHT. Ophthalmology outcomes are strongly associated with degree of neurological impairment. Best outcomes were achieved with PPV performed between 2 and 5 weeks after trauma. Opportunity to plan surgery within this time frame indicates a good neurological prospect and prevents deprivation amblyopia.
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Affiliation(s)
- Pavel Kozner
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jana Stepankova
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Dagmar Dotrelova
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Gencturk M, Cam I, Koksel Y, McKinney AM. Role of Susceptibility-Weighted Imaging in Detecting Retinal Hemorrhages in Children with Head Trauma. Clin Neuroradiol 2020; 31:611-617. [DOI: 10.1007/s00062-020-00939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/09/2020] [Indexed: 11/25/2022]
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Byrne MP, McMillan KR, Coats B. Morphological Analysis of Retinal Microvasculature to Improve Understanding of Retinal Hemorrhage Mechanics in Infants. Invest Ophthalmol Vis Sci 2020; 61:16. [PMID: 32176264 PMCID: PMC7401705 DOI: 10.1167/iovs.61.3.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose In this experimental study, we quantify retinal microvasculature morphological features with depth, region, and age in immature and mature ovine eyes. These data identify morphological vulnerabilities in young eyes to inform the mechanics of retinal hemorrhage in children. Methods Retinal specimens from the equator and posterior pole of preterm (n = 4) and adult (n = 9) sheep were imaged using confocal microscopy. Vessel segment length, diameter, angular asymmetry, tortuosity, and branch points were quantified using a custom image segmentation code. Significant differences were identified through two-way ANOVAs and correlation analyses. Results Vessel segment lengths were significantly shorter in immature eyes compared to adults (P < 0.003) and were significantly shorter at increasing depths in the immature retina (P < 0.04). Tortuosity significantly increased with depth, regardless of age (P < 0.05). These data suggest a potential vulnerability of vasculature in the deeper retinal layers, particularly in immature eyes. Preterm retina had significantly more branch points than adult retina in both the posterior pole and equator, and the number increased significantly with depth (P < 0.001). Conclusions The increased branch points and decreased segment lengths in immature microvasculature suggest that infants will experience greater stress and strain during traumatic loading compared to adults. The increased morphological vulnerability of the immature microvasculature in the deeper layers of the retina suggest that intraretinal hemorrhages have a greater likelihood of occurring from trauma compared to preretinal hemorrhages. The morphological features captured in this study lay the foundation to explore the mechanics of retinal hemorrhage in infants and identify vulnerabilities that explain patterns of retinal hemorrhage in infants.
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Modeling Hypertension as a Contributor to Retinal Hemorrhaging from Abusive Head Trauma. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:4714927. [PMID: 32566113 PMCID: PMC7256766 DOI: 10.1155/2020/4714927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/31/2019] [Accepted: 01/20/2020] [Indexed: 12/05/2022]
Abstract
Retinal hemorrhaging (RH) is indicative and prevalent in abusive head trauma (AHT)—yet the direct cause of the RH from AHT is unknown. Our hypothesis is that RH in AHT is the combination of shaking forces and hypertension. This combination of effects explains why RH is not normally observed in common childhood accidents but is nearly exclusively observed in AHT. An experimental model using porcine eyes was designed to ascertain the required pressure change for sudden RH and, via a computer model, the subsequent stress increase in blood vessels. The porcine eyes were cannulated via the maxillary artery and pressurized until perfusion and RH were observed. Fluid was injected into the head with a computer-controlled continuous flow syringe pump; video of the fundus was recorded during perfusion; and the pressure of the fluid entering the eye was recorded as well. A computer model was created in COMSOL to simulate loading from hypertension, shaking, and the combination of the forces. This model was validated via experimental data collected from the porcine model. It was found that hypertension or shaking alone did not cause an increase in stress required to cause RH. But when the loading of shaking and hypertension was combined, as would occur in AHT, the stress increases were greater than those extrapolated from the porcine model and would cause RH.
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Biomechanism of resistance to retinal injury in woodpecker’s eyes. SCIENCE CHINA-LIFE SCIENCES 2020; 63:592-598. [DOI: 10.1007/s11427-019-1664-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/01/2019] [Indexed: 10/24/2022]
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Kelly JP, Feldman K, Wright J, Ganti S, Metz JB, Weiss A. Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages. Doc Ophthalmol 2020; 141:111-126. [PMID: 32052259 DOI: 10.1007/s10633-020-09756-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/06/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate retinal function and visual outcomes in infants with retinal hemorrhages due to non-accidental trauma (NAT). METHODS This is a retrospective review of full-field or multifocal electroretinogram (ERG) recordings, visual acuity in log minimum angle of resolution (logMAR), clinical status, and neuroimaging. Multifocal ERGs from the central 40° were compared to corresponding fundus imaging. Visual acuity was measured by Teller cards at follow-up. ERGs were compared to controls recorded under anesthesia. RESULTS Sixteen children met inclusion criteria (14 recorded during the acute phase and 2 during long-term follow-up). During the acute phase, ERGs (n = 4 full field; n = 10 multifocal ERG) showed abnormal amplitude, latency, or both in at least one eye. Ten subjects had significantly reduced responses in both eyes, 3 of which had an ERG dominated by a negative waveform (absent b-wave or P1). The remaining six subjects had responses in one eye that were near normal (≥ 50% of controls). ERGs were sometimes abnormal in local areas without hemorrhage. ERGs could be preserved in local areas adjacent to traumatic retinoschisis. Two subjects with reduced visual acuity had belated ERGs: One had an abnormal macular ERG and the other had a normal macular ERG implying cortical visual impairment. At follow-up, 10 of 14 subjects had significant visual acuity loss (≥ 0.7 age-corrected logMAR); four subjects had mild vision loss (≤ 0.5 age-corrected logMAR). Visual acuity outcome was not reliably associated with the fundus appearance in the acute phase. All subjects with a negative ERG waveform had severe vision loss on follow-up. CONCLUSIONS Retinal dysfunction was common during the acute phase of NAT. A near normal appearing fundus did not imply normal retinal function, and ERG abnormality did not always predict a poor visual acuity outcome. However, a negative ERG waveform was associated severe visual acuity loss. Potential artifacts of retinal hemorrhages and anesthesia could not fully account for multifocal ERG abnormalities. Retinal function can be preserved in areas adjacent to traumatic retinoschisis.
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Affiliation(s)
- John P Kelly
- Roger H. Johnson Vision Clinic, Seattle Children's Hospital, Division of Ophthalmology, OA.5.342, Seattle, WA, 98105, USA.
- Department of Ophthalmology, University of Washington, Seattle, USA.
| | - Kenneth Feldman
- Seattle Children's Hospital, Children's Protection Program, Seattle, USA
- Division of General Pediatrics, University of Washington, Seattle, USA
| | - Jason Wright
- Division of Radiology, Seattle Children's Hospital, Seattle, USA
| | - Sheila Ganti
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, USA
| | - James B Metz
- Department of Pediatrics, University of Vermont, Burlington, USA
| | - Avery Weiss
- Department of Ophthalmology, University of Washington, Seattle, USA
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Silloca‐Cabana EO, Hathuc VM, Harrison WT, Lantz PE. Hemorrhagic Retinopathy and Optic Nerve Sheath Hemorrhage Associated With Fatal Subarachnoid Hemorrhage from a Ruptured Intracranial Aneurysm Due to Segmental Fibromuscular Dysplasia. J Forensic Sci 2019; 65:649-654. [DOI: 10.1111/1556-4029.14196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/21/2019] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - Vivian M. Hathuc
- Department of Pathology Ascension Genesys Hospital 1 Genesys Pkwy Grand Blanc MI 48439
| | - William T. Harrison
- Department of Pathology Wake Forest Baptist Health Medical Center Blvd. Winston Salem NC 27157
| | - Patrick E. Lantz
- Department of Pathology Wake Forest Baptist Health Medical Center Blvd. Winston Salem NC 27157
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Donaldson L, Isaza G, Baird B, Chaudhary V. Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma. Can J Ophthalmol 2019; 55:172-178. [PMID: 31712016 DOI: 10.1016/j.jcjo.2019.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/20/2019] [Accepted: 07/18/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT). METHODS Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017. RESULTS Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%). CONCLUSIONS A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.
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Affiliation(s)
- Laura Donaldson
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont
| | - Gloria Isaza
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont..
| | - Burke Baird
- Division of Child Maltreatment Pediatrics, McMaster University Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ont
| | - Varun Chaudhary
- Division of Ophthalmology, McMaster University Department of Surgery, McMaster Children's Hospital, Hamilton, Ont
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Child abuse and the pediatric surgeon: A position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association. J Pediatr Surg 2019; 54:1277-1285. [PMID: 30948199 DOI: 10.1016/j.jpedsurg.2019.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/24/2019] [Accepted: 03/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The pediatric surgeon is in a unique position to assess, stabilize, and manage a victim of child physical abuse (formerly nonaccidental trauma [NAT]) in the setting of a formal trauma system. METHODS The American Pediatric Surgical Association (APSA) endorses the concept of child physical abuse as a traumatic disease that justifies the resource utilization of a trauma system to appropriately evaluate and manage this patient population including evaluation by pediatric surgeons. RESULTS APSA recommends the implementation of a standardized tool to screen for child physical abuse at all state designated trauma or ACS verified trauma and children's surgery hospitals. APSA encourages the admission of a suspected child abuse patient to a surgical trauma service because of the potential for polytrauma and increased severity of injury and to provide reliable coordination of services. Nevertheless, APSA recognizes the need for pediatric surgeons to participate in a multidisciplinary team including child abuse pediatricians, social work, and Child Protective Services (CPS) to coordinate the screening, evaluation, and management of patients with suspected child physical abuse. Finally, APSA recognizes that if a pediatric surgeon suspects abuse, a report to CPS for further investigation is mandated by law. CONCLUSION APSA supports data accrual on abuse screening and diagnosis into a trauma registry, the NTDB and the Pediatric ACS TQIP® for benchmarking purposes and quality improvement.
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Shi A, Kulkarni A, Feldman KW, Weiss A, McCourt EA, Schloff S, Partington M, Forbes B, Geddie BE, Bierbrauer K, Phillips PH, Rogers DL, Abed Alnabi W, Binenbaum G, Levin AV. Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes. Pediatrics 2019; 143:peds.2018-1182. [PMID: 30630868 PMCID: PMC6361344 DOI: 10.1542/peds.2018-1182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. METHODS We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. RESULTS Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. CONCLUSIONS Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.
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Affiliation(s)
- Angell Shi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Abhaya Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Avery Weiss
- Ophthalmology, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Emily A. McCourt
- Department of Ophthalmology, Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Schloff
- Associated Eye Care, St Paul, Minnesota;,Department of Ophthalmology and Visual Neurosciences, Children’s Minnesota St Paul Hospital, St Paul, Minnesota
| | - Michael Partington
- Department of Neurosurgery, Gillette Children’s Specialty Healthcare, St Paul, Minnesota
| | - Brian Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brooke E. Geddie
- Division of Pediatric Ophthalmology, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Karin Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul H. Phillips
- Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas;,Department of Ophthalmology, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - David L. Rogers
- Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Waleed Abed Alnabi
- Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and,Médecins Sans Frontieres, Amman, Jordan
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V. Levin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania;,Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and
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Shouldice M, Al-Khattabi F, Thau A, McIntyre S, Ng WKY, Levin AV. Traumatic macular retinoschisis in infants and children. J AAPOS 2018; 22:433-437.e2. [PMID: 30394342 DOI: 10.1016/j.jaapos.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide detailed description of pediatric traumatic retinoschisis. METHODS The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.
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Affiliation(s)
| | - Fadiah Al-Khattabi
- College of Medicine at Alfaisal University, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Avrey Thau
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan McIntyre
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Wendy K Y Ng
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Alex V Levin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania.
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Moshfeghi DM. Terson Syndrome in a Healthy Term Infant: Delivery-Associated Retinopathy and Intracranial Hemorrhage. Ophthalmic Surg Lasers Imaging Retina 2018; 49:e154-e156. [PMID: 30395678 DOI: 10.3928/23258160-20181002-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/28/2018] [Indexed: 11/20/2022]
Abstract
A term healthy infant was noted to have cephalohematoma following normal spontaneous vaginal delivery (NSVD). At 9 days of age, the attending team performed wide-angle remote digital fundus imaging and the left eye was noted to have scattered multi-laminar hemorrhages. Magnetic resonance imaging was performed which revealed occipital infarct and subarachnoid hemorrhage. A diagnosis of neonatal Terson syndrome was made. The child remained asymptomatic and the fundus hemorrhages resolved without sequelae. This case represents the first documented instance of Terson syndrome following NSVD and may represent a possible etiology of the common newborn retinal hemorrhage. Alternative terminology - delivery-associated retinopathy and intracranial hemorrhages - is proposed to describe these findings. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e154-e156.].
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Abstract
Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.
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Morgan LA, Fouzdar Jain S, Svec A, Svec C, Haney SB, Allbery S, High R, Suh DW. Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma. Clin Ophthalmol 2018; 12:1505-1510. [PMID: 30174411 PMCID: PMC6110291 DOI: 10.2147/opth.s163734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose Child abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients. Patients and methods A retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children’s Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases. Results Of the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10). Conclusion AHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.
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Affiliation(s)
| | | | - Austin Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Claire Svec
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Robin High
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, NE, USA, .,University of Nebraska Medical Center, Omaha, NE, USA
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Christian CW, Levin AV, Flaherty EG, Sirotnak AP, Budzak AE, Gavril AR, Haney SB, Idzerda SM, Laskey A, Legano LA, Messner SA, Moles RL, Palusci VJ, Karr DJ, Bradford GE, Nischal K, Roarty JD, Rubin SE, Suh DW. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2018; 142:peds.2018-1411. [PMID: 30037976 DOI: 10.1542/peds.2018-1411] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
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Affiliation(s)
- Cindy W. Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alex V. Levin
- Departments of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital and Departments of Ophthalmology and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018; 48:1048-1065. [PMID: 29796797 DOI: 10.1007/s00247-018-4149-1] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [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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Abstract
PURPOSE To demonstrate vitreoretinal traction as a mechanism for perimacular folds in abusive head trauma. METHODS We performed gross and histopathologic examination of eyes of children with suspected abusive head trauma and identified those with typical perimacular folds. Information was collected regarding the incident that led to the child's death and systemic manifestations noted at autopsy. Eyes were prepared in a fashion that allowed for demonstration of the vitreoretinal interface. RESULTS Ten eyes of five patients (2-13 months) were examined. All patients had systemic manifestations of abusive trauma including intracranial injury. All cases provided evidence of vitreoretinal traction producing perimacular folds. Condensed vitreous was seen attached to the apices of the retinal folds, and the detached internal limiting membrane comprising the inner surfaces of the schisis cavity. Four cases showed severe bilateral multilayered symmetric retinal hemorrhages extending to the ora serrata. All cases showed optic nerve sheath subdural hemorrhage and subarachnoid hemorrhage. Orbital hemorrhage was unilateral in two cases and bilateral in three cases. Four cases showed orbital fat hemorrhage. One case showed extraocular muscle sheath and cranial nerve sheath hemorrhage. Two cases showed juxtapapillary intrascleral hemorrhage. CONCLUSION Vitreoretinal traction is the likely mechanism of perimacular folds in abusive head trauma.
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Kim SY, Morgan LA, Baldwin AJ, Suh DW. Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery. J AAPOS 2018; 22:139-144. [PMID: 29548839 DOI: 10.1016/j.jaapos.2017.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 12/06/2017] [Accepted: 12/19/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Retinal hemorrhage (RH) is one of the hallmarks of abusive head trauma (AHT); however, RH is also encountered with normal vaginal deliveries (NVD) and thus presents the clinician with a diagnostic dilemma. The purpose of this study was to compare RHs in AHT with those of NVD. METHODS Records of with AHT and NVD infants with RH evaluated from 2013 to 2015 were reviewed retrospectively. Pattern, size, extent, and severity were compared using RetCam images. Severities were calculated using the RH grading scale. RESULTS A total of 20 patients with AHT and 200 NVD infants were included. RH size was significantly larger in AHT patients compared to the NVD group (3.1 ± 0.512 vs 0.96 ± 0.046 disk diameters, resp.). The AHT group also demonstrated a higher RH incidence involving all three retinal layers compared to the NVD group (60% vs 0.6%, resp. [P < 0.001]). Vitreous hemorrhages were more common in the AHT group compared to the NVD group (54.3% vs 1.5% [P < 0.001]). Also, the grading scale demonstrated higher scores in the AHT group than the NVD group (7.15 ± 0.948 vs 3.59 ± 0.274, resp.). CONCLUSIONS AHT and NVD share similar retinal findings, but they also have unique differentiators. In our subjects, AHT presented with more severe retinal findings than NVD, including larger RH size, a higher percentage involving all three retinal layers, a higher percentage of vitreous hemorrhages, and higher RH grading scale scores. Also, NVD retinal hemorrhages resolved quickly, within 4 weeks of birth in 95% of the patients.
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Affiliation(s)
- So Young Kim
- Children's Hospital and Medical Center, Omaha, Nebraska
| | - Linda A Morgan
- Children's Hospital and Medical Center, Omaha, Nebraska.
| | | | - Donny W Suh
- Children's Hospital and Medical Center, Omaha, Nebraska; University of Nebraska Medical Center, Omaha, Nebraska
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Wu AL, See LC, Hsia SH, Tu HT, Wang NK, Huang JL, Hwang YS, Lai CC, Wu WC. Pediatric abusive head trauma in Taiwan: clinical characteristics and risk factors associated with mortality. Graefes Arch Clin Exp Ophthalmol 2018; 256:997-1003. [PMID: 29302787 DOI: 10.1007/s00417-017-3863-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 12/11/2017] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To report the clinical characteristics of abusive head trauma (AHT) in Taiwan and identify the risk factors associated with mortality of these patients. METHODS Children with clinically diagnosed AHT from January 1, 2000, to October 31, 2015 were reviewed. The demographic data, clinical features, and associated retinal and radiologic findings were analyzed. The multivariable logistic regression model analysis was performed to identify the risk factors associated with in-hospital mortality. RESULTS A total of 75 children were included. The mean age was 7.31 ± 6.57 months (range, 1-36 months). Retinal hemorrhages were detected in 69 children with AHT (92%). The majority of retinal hemorrhages were characterized by hemorrhagic numbers higher than ten (74.7%), multi-layered (54.7%), and extension beyond the posterior pole to the peripheral retina (73.3%). Twenty children (26.7%) had macular retinoschisis. As a direct result of AHT, ten children died in the hospital (13.3%). Logistic regression showed that respiratory distress or apnea (adjusted odds ratio [OR] = 22.46; 95% confidence interval [CI], 2.24-225.33; P = .0082), vomiting (adjusted OR = 11.94; 95% CI, 1.31-108.403; P = .0276), retinal finding of macular retinoschisis (adjusted OR = 8.9; 95% CI, 1.01-78.65; P = .0493), and the presence of subarachnoid hemorrhage (SAH) (adjusted OR = 15.17; 95% CI, 1.40-64.84; P = .0255) were independently associated with mortality. CONCLUSIONS Respiratory distress or apnea, vomiting, SAH, and macular retinoschisis are independently associated with mortality in abusive head trauma. A complete ophthalmologic examination with the immediate visualization of intraocular injury should be performed to clarify the likelihood of child abuse and predict a potential poor neurologic outcome.
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Affiliation(s)
- An-Lun Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Rd, Taoyuan, Taiwan, 33375
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Pediatric Critical Care Medicine, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Tzu Tu
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nan-Kai Wang
- Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Rd, Taoyuan, Taiwan, 33375
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Jing-Long Huang
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Rd, Taoyuan, Taiwan, 33375
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Rd, Taoyuan, Taiwan, 33375
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Hsin Rd, Taoyuan, Taiwan, 33375.
- Chang Gung University, College of Medicine, Taoyuan, Taiwan.
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Del Bigio MR, Phillips SM. Retroocular and Subdural Hemorrhage or Hemosiderin Deposits in Pediatric Autopsies. J Neuropathol Exp Neurol 2017; 76:313-322. [PMID: 28340081 DOI: 10.1093/jnen/nlx010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The presence of hemosiderin in the optic nerve sheath and/or retina is sometimes used to estimate the timing of injury in infants or children with suspected non-accidental head trauma. To determine the prevalence of hemosiderin in deaths not associated with trauma, we performed a prospective study of retroocular orbital tissue, cranial convexity, and cervical spinal cord dura mater in infants and children <2.5 years age. In 53 cases of non-traumatic death, approximately 70% had blood or hemosiderin within the orbital fat, ocular muscles, and parasagittal cranial and/or cervical spinal subdural compartment. This bleeding is likely a consequence of the birth process. None had evidence of hemorrhage within the optic nerve sheath. Premature birth was less likely associated with orbital tissue hemorrhage. Caesarean section birth (mainly nonelective) was not associated with lower prevalence. Residual hemosiderin was identifiable up to 36 weeks postnatal age, suggesting gradual disappearance after birth. Cardiopulmonary resuscitation (performed in the majority of cases) was not associated with acute hemorrhage. In 9 traumatic deaths, 6 had blood and/or hemosiderin within the optic nerve sheath. Knowledge of the potential presence and resolution of hemosiderin in these locations is important for medicolegal interpretation of childhood deaths associated with head or brain injury.
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Affiliation(s)
- Marc R Del Bigio
- Department of Pathology, University of Manitoba, Winnipeg, Canada.,Diagnostic Services Manitoba, Manitoba, Winnipeg, Canada.,Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
| | - Susan M Phillips
- Department of Pathology, University of Manitoba, Winnipeg, Canada.,Diagnostic Services Manitoba, Manitoba, Winnipeg, Canada
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44
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Zuccoli G, Khan AS, Panigrahy A, Tamber MS. In Vivo Demonstration of Traumatic Rupture of the Bridging Veins in Abusive Head Trauma. Pediatr Neurol 2017; 72:31-35. [PMID: 28465135 DOI: 10.1016/j.pediatrneurol.2017.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/28/2017] [Accepted: 04/01/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE In victims of abusive head trauma, bridging vein thrombosis is a common finding on magnetic resonance imaging. We aimed to evaluate the utility of high-resolution coronal susceptibility-weighted imaging (SWI) in depicting bridging vein thrombosis as well as to verify the morphology of the bridging vein thrombosis on axial SWI. We additionally analyzed the correlations between bridging vein thrombosis or bridging vein deformation and other magnetic resonance imaging findings that often occur in association with abusive head trauma. METHODS Seventeen patients with abusive head trauma were retrospectively evaluated for the presence of thrombosis on axial SWI. The affected veins were localized on coronal SWI, and the strength of association between the presence of bridging vein thrombosis on axial versus high-resolution coronal SWI was determined. RESULTS Of 11 patients identified with thrombosis on axial SWI, high-resolution coronal SWI verified bridging vein thrombosis in four individuals (36%). The previously reported "tadpole sign" on axial images did not predict bridging vein thrombosis on coronal SWI (odds ratio = 0.3 [0.02, 5.01], P = 0.538). Volumetric coronal SWI disclosed additional irregularities of the bridging vein walls which was associated with the presence of subdural hematoma on magnetic resonance imaging (P = 0.03), suggesting traumatic injury. CONCLUSION Coronal SWI confirmed thrombosis of the bridging veins only in a minority of cases. Diffusely irregular contours of the veins observed on high-resolution coronal SWI was a major finding in our study. Disruption of the normal anatomy of the bridging veins in abusive head trauma further supports the traumatic nature of the disease.
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Affiliation(s)
- Giulio Zuccoli
- Department of Radiology, Section of Neuroradiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.
| | - Abdullah S Khan
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Radiology, Section of Neuroradiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Mandeep S Tamber
- Department of Pediatric Neurosurgery, Children's Hospital of Pittsburgh at UPMC, Pittsburgh, Pennsylvania
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45
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Lynøe N, Elinder G, Hallberg B, Rosén M, Sundgren P, Eriksson A. Insufficient evidence for 'shaken baby syndrome' - a systematic review. Acta Paediatr 2017; 106:1021-1027. [PMID: 28130787 DOI: 10.1111/apa.13760] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/24/2017] [Indexed: 01/08/2023]
Abstract
Shaken baby syndrome has typically been associated with findings of subdural haematoma, retinal haemorrhages and encephalopathy, which are referred to as the triad. During the last decade, however, the certainty with which the triad can indicate that an infant has been violently shaken has been increasingly questioned. The aim of this study was to determine the diagnostic accuracy of the triad in detecting that an infant had been shaken. The literature search was performed using PubMed, Embase and the Cochrane Library up to October 15, 2015. Relevant publications were assessed for the risk of bias using the QUADAS tool and were classified as having a low, moderate or high risk of bias according to predefined criteria. The reference standards were confessions or witnessed cases of shaking or accidents. The search generated 3773 abstracts, 1064 were assessed as possibly relevant and read as full texts, and 30 studies were ultimately included. Of these, 28 were assessed as having a high risk of bias, which was associated with methodological shortcomings as well as circular reasoning when classifying shaken baby cases and controls. The two studies with a moderate risk of bias used confessions and convictions when classifying shaken baby cases, but their different designs made a meta-analysis impossible. None of the studies had a low risk of bias. CONCLUSION The systematic review indicates that there is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low-quality evidence). It was also demonstrated that there is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low-quality evidence).
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Affiliation(s)
- Niels Lynøe
- Stockholm Centre for Healthcare Ethics; Karolinska Institutet; Stockholm Sweden
| | - Göran Elinder
- Department of Clinical Science and Education; Södersjukhuset; Karolinska Institutet; Stockholm Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology; Karolinska Institutet; and Karolinska University Hospital; Stockholm Sweden
| | - Måns Rosén
- Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Pia Sundgren
- Department of Diagnostic Radiology, Clinical Sciences; Lund University; Lund Sweden
| | - Anders Eriksson
- Department of Community Medicine and Rehabilitation; Forensic Medicine; Umeå University Umeå Sweden
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46
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Minns RA, Jones PA, Tandon A, Fleck BW, Mulvihill AO, Minns FC. Raised intracranial pressure and retinal haemorrhages in childhood encephalopathies. Dev Med Child Neurol 2017; 59:597-604. [PMID: 28369828 DOI: 10.1111/dmcn.13419] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2017] [Indexed: 11/28/2022]
Abstract
AIM To explore the relationship between raised intracranial pressure (RICP) and retinal haemorrhages in traumatic and non-traumatic childhood encephalopathies. METHOD A prospective study of 112 children (35 females and 77 males, age range 0.01mo-17y 8.3mo; mean 5y 8.6mo, median 4y 5.6mo) included 57 accidental traumatic brain injuries (ATBIs), 21 inflicted traumatic brain injuries (ITBIs), and 34 non-traumatic encephalopathy cases. Measurements included intracranial pressure (ICP), cerebral perfusion pressure, pressure-time index of ICP, and number, zone, and layer of retinal haemorrhages on retinal imaging. RESULTS Group I had measured elevated ICP (n=42), Group II had clinical and/or radiological signs of RICP (n=21), and Group III had normal ICP (n=49). In the combined Groups I and II, 38% had retinal haemorrhages. Multiple logistic regression confirmed that the presence of retinal haemorrhages was significantly related to the presence of RICP independent of age and aetiology; however, the occurrence and overall numbers were not significantly related to the specific ICP level. The numbers of intraretinal (nerve-fibre layer and dot blot) retinal haemorrhages were significantly greater in those with RICP. The ITBI population was significantly different from the other combined aetiological categories. INTERPRETATION The study results indicate a complex RICP/retinal haemorrhage relationship. There was no evidence of existing retinal haemorrhages being exacerbated or new retinal haemorrhages developing during periods of confirmed RICP.
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Affiliation(s)
- Robert A Minns
- Department Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Patricia A Jones
- Department Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Brian W Fleck
- Princess Alexandra Eye Pavilion, Edinburgh, UK.,Royal Hospital for Sick Children, Edinburgh, UK
| | - Alan O Mulvihill
- Princess Alexandra Eye Pavilion, Edinburgh, UK.,Royal Hospital for Sick Children, Edinburgh, UK
| | - Fiona C Minns
- Department of Radiology, New Royal Infirmary, Edinburgh, UK
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47
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The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital. Forensic Sci Int 2017; 276:5-11. [PMID: 28458085 DOI: 10.1016/j.forsciint.2017.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/04/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
Abstract
Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.
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48
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Binenbaum G, Reid JE, Rogers DL, Jensen AK, Billinghurst LL, Forbes BJ. Patterns of retinal hemorrhage associated with pediatric cerebral sinovenous thrombosis. J AAPOS 2017; 21:23-27. [PMID: 28087346 DOI: 10.1016/j.jaapos.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 10/01/2016] [Accepted: 10/06/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) has been proposed as an alternative cause of retinal hemorrhage (RH) in children being evaluated for abusive head trauma. This study investigated the prevalence and characteristics of RH in children with CSVT. METHODS The medical records of children >6 weeks of age with newly diagnosed CSVT and fundus examination by an ophthalmologist were examined retrospectively. Primary outcomes were presence and patterns of RH. RESULTS A total of 29 children (median age, 9 years; range, 7 weeks to 17 years) were studied. Of these, 5 (17%) had RH, in 4 of whom RH were peripapillary, superficial, intraretinal, and adjacent to a swollen optic disk. In the fifth child, who had meningitis, sepsis, and multiple cerebral infarcts, there were a moderate number of posterior pole intraretinal hemorrhages. Eighteen children (62%) had optic disk swelling. In 13 children, cerebrospinal fluid opening pressure was recorded (range, 27-59 cm H2O). CSVT risk factors included meningitis, mastoiditis, and hypercoagulability. CONCLUSIONS RH in pediatric CSVT was uncommon. When RHs were present, the appearance matched RH patterns known to be caused by medical conditions, such as raised intracranial pressure and sepsis, also present in these children. These findings suggest that the RHs are due to these other causes and not directly to CSVT itself. In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.
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Affiliation(s)
- Gil Binenbaum
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Julia E Reid
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Anne K Jensen
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lori L Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian J Forbes
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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49
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Jenny CA, Bertocci G, Fukuda T, Rangarajan N, Shams T. Biomechanical Response of the Infant Head to Shaking: An Experimental Investigation. J Neurotrauma 2017; 34:1579-1588. [PMID: 27931172 DOI: 10.1089/neu.2016.4687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Controversy exists regarding whether violent shaking is harmful to infants in the absence of impact. In this study, our objective was to characterize the biomechanical response of the infant head during shaking through use of an instrumented anthropomorphic test device (commonly referred to as a "crash test dummy" or surrogate) representing a human infant and having improved biofidelity. A series of tests were conducted to simulate violent shaking of an infant surrogate. The Aprica 2.5 infant surrogate represented a 5th percentile Japanese newborn. A 50th percentile Japanese adult male was recruited to shake the infant surrogate in the sagittal plane. Triaxial linear accelerometers positioned at the center of mass and apex of the head recorded accelerations during shaking. Five shaking test series, each 3-4 sec in duration, were conducted. Outcome measures derived from accelerometer recordings were examined for trends. Head/neck kinematics were characterized during shaking events; mean peak neck flexion was 1.98 radians (113 degrees) and mean peak neck extension was 2.16 radians (123 degrees). The maximum angular acceleration across all test series was 13,260 radians/sec2 (during chin-to-chest contact). Peak angular velocity was 105.7 radians/sec (during chin-to-chest contact). Acceleration pulse durations ranged from 72.1 to 168.2 ms. Using an infant surrogate with improved biofidelity, we found higher angular acceleration and higher angular velocity than previously reported during infant surrogate shaking experiments. Findings highlight the importance of surrogate biofidelity when investigating shaking.
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Affiliation(s)
- Carole A Jenny
- 1 Department of Pediatrics, University of Washington School of Medicine , Seattle, Washington
| | - Gina Bertocci
- 2 Department of Bioengineering, University of Louisville , Louisville, Kentucky
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50
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Saunders D, Raissaki M, Servaes S, Adamsbaum C, Choudhary AK, Moreno JA, van Rijn RR, Offiah AC. Throwing the baby out with the bath water - response to the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) report on traumatic shaking. Pediatr Radiol 2017; 47:1386-1389. [PMID: 28785782 PMCID: PMC5608779 DOI: 10.1007/s00247-017-3932-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 11/23/2022]
Affiliation(s)
- Dawn Saunders
- 0000000121901201grid.83440.3bGreat Ormond Street Hospital NHS Trust for Children, Institute of Child Health, WC1N 3JH, London, UK
| | - Maria Raissaki
- grid.412481.aDepartment of Radiology, University Hospital of Heraklion, Iraklio, Greece ,0000 0004 0576 3437grid.8127.cUniversity of Crete, Heraklion, Crete, Greece
| | - Sabah Servaes
- 0000 0004 1936 8972grid.25879.31The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | - Catherine Adamsbaum
- 0000 0001 2171 2558grid.5842.bAP-HP, Bicêtre Hospital, Pediatric Imaging Department, Paris Sud University, Bicêtre, France
| | - Arabinda Kumar Choudhary
- 0000 0004 0458 9676grid.239281.3Department of Medical Imaging, Alfred I. duPont Hospital for Children, Wilmington, DE USA
| | | | - Rick R. van Rijn
- 0000000404654431grid.5650.6Department of Radiology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Amaka C. Offiah
- 0000 0004 1936 9262grid.11835.3eAcademic Unit of Child Health, Sheffield Childrens NHS Foundation Trust, University of Sheffield, Sheffield, UK
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