Evolution of the cranial computed tomography scan in child abuse

Natural history of traumatic meningeal bleeding in infants: semiquantitative analysis of serial CT scans in corroborated cases

BACKGROUND

The natural history of posttraumatic meningeal bleeding in infants is poorly documented, and the differences between inflicted head injury (IHI) and accidental trauma (AT) are debated. Autopsy findings have suggested that anoxia also plays a role in bleeding; however, these findings may not reflect what occurs in live trauma patients.

PURPOSE

We studied the natural history of traumatic meningeal bleeding in infants using serial computed tomography (CT) scans in corroborated IHI and AT.

MATERIALS AND METHODS

From our prospective series, we selected corroborated cases (confessed IHI or AT having occurred in public), who underwent at least three CT scans in the acute phase. We performed a semiquantitative analysis of meningeal bleeding using a four-tier scale (absent, faint, frank, and thick) derived from the Fisher grading for aneurysmal bleeding in four regions of interest (convexity, falx cerebri, sagittal sinus, and tentorium cerebelli).

RESULTS

We studied 20 cases: ten IHI and ten AT. Bleeding was maximal at the convexity initially, then increased along the falx and sagittal sinus, and then along the tentorium. Decrease and disappearance of blood was variable according to the site and the initial quantity of blood. We found no difference between IHI and AT.

CONCLUSION

Our findings suggest that the primary site of meningeal bleeding in infantile head trauma is the convexity of the brain; blood cells then migrate toward the midline following the flow of cerebrospinal fluid circulation and inferiorly following gravity. The pattern of bleeding in traumatic cases appears similar in IHI and AT but different from anoxic lesions.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review

AIMS

To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).

MATERIALS AND METHODS

A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.

RESULTS

Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.

CONCLUSIONS

In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.

Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic, and forensic implications

OBJECTIVES

The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury.

DESIGN

This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006.

SETTING

Children's Hospital, San Diego.

PATIENTS

Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state.

CONCLUSIONS

These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.

Arterial dissection and stroke following child abuse: case report and review of the literature

INTRODUCTION

Arterial dissection and stroke following trauma are seen frequently. Although similar mechanisms occur for trauma and child abuse, no reports of stroke have been observed in the literature.

CASE REPORTS

Two patients successively presented to our institution with acute onset of neurological deficit and stroke. Further evaluation disclosed child abuse as an underlying condition leading to the strokes. Child protection services were contacted immediately after admission of the patients and further measures were taken.

CONCLUSIONS

Recognition of potential cases of child abuse is crucial. Early intervention and cessation of interaction between the aggressor and the child are important measures to be taken in all situations when there is strong evidence of suggestive examination of child abuse.

Shaken baby syndrome without intracranial hemorrhage on initial computed tomography

OBJECTIVE

We sought to describe the unique characteristics of children diagnosed with shaken baby syndrome (SBS) despite the absence of intracranial hemorrhage on cranial computerized tomography (CT) on hospital admission.

METHODS

Using an international e-mail-based listserv for professionals with an interest in child abuse, we identified and reviewed the charts of children hospitalized in different medical centers who were diagnosed with SBS although CT disclosed no signs of intracranial bleeding. Children with normal imaging were not included.

RESULTS

Eight cases were identified. All children had cerebral edema in CT, which was severe on 7/8 cases (88%). All of these children had extensive retinal hemorrhage. The prognosis was poor; 5/8 infants died (63% mortality), and the rest had permanent neurologic damage.

CONCLUSION

The diagnosis of SBS can be established even when CT at presentation does not demonstrate intracranial hemorrhage. We hypothesize that rapidly developing cerebral edema may cause increased intracranial pressure and tamponade that prevents the accumulation of intracranial blood. The prognosis in these cases is grave.

Normal computerized tomography of brain in children with shaken baby syndrome

OBJECTIVE

To characterize the clinical presentation and clinical course of shaken baby syndrome (SBS) with normal cranial computerized tomography (CT) on admission and to suggest further diagnostic procedures in such circumstances.

METHODS

Using a worldwide listserv designed to facilitate discussion in the field of child abuse and neglect, we solicited case information for children hospitalized in different medical centers, who were diagnosed with SBS and had a normal CT scan on admission.

RESULTS

Nine cases were identified. While all children had an abnormal neurologic examination on admission, eight had a normal CT, and one had "widening of cranial sutures." In four cases, subdural hemorrhage was diagnosed on magnetic resonance imaging (MRI) 3 to 7 days after admission. Five children had bone fractures. The neurological outcome was normal in four of nine cases. Five children had long-term neurologic damage. The diagnosis of SBS was supported by either perpetrator confession, characteristic evolution of brain abnormalities on CT or MRI, inconsistent or absent explanatory history, and/or other social risk factors.

CONCLUSION

The diagnosis of SBS can be established even when brain CT is normal on admission. The documentation of retinal hemorrhages is of primary importance in establishing the diagnosis of SBS in these cases.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

Cultural evidence, child maltreatment, and the law

This article addresses child maltreatment law's use of cultural evidence. Such evidence, offered by immigrant and nonmainstream parents accused of child maltreatment, serves to mitigate intervention in families or to minimize punishment for the offense. The article explores how the two areas of law that currently regulate child maltreatment--criminal and child welfare law--approach the use of such evidence. Civil, child welfare law tends to formally accept and allow for the use of cultural evidence. Criminal law rejects cultural evidence to mount a formal cultural defense that would automatically exempt individuals from punishment for criminal acts, but the system still allows cultural evidence to affect legal decisions. How both systems actually use cultural evidence in practice, however, remains to be determined. The article offers an approach to encourage both legal systems to evaluate and consider cultural evidence more systematically and critically. The analysis also addresses likely objections to the proposed alternatives.

The role of cranial MRI in identifying patients suffering from child abuse and presenting with unexplained neurological findings

OBJECTIVE

The aim of this study was to demonstrate the usefulness of cerebral MRI to detect possible child abuse in children with unexplained neurologic findings.

METHOD

Between 1990 and 1997, 208 children were referred for suspected physical child abuse to the Child Protection Clinic of Ste-Justine Hospital, a tertiary care pediatric hospital. Among them, 39 children presented initially with neurological findings. For 27 of them, the CT Scan results prompted the diagnosis of child abuse. However, in 12 children, even if a CT-Scan was performed, the diagnosis and/or the mechanisms of the neurologic distress remained obscure. Investigation was completed with MRI study in those 12 cases.

RESULTS

MRI findings were diagnostic for physical abuse in eight cases. A diagnosis of child abuse was made in two more cases by a combination of MRI and skeletal survey findings. In one case, MRI was suggestive but the diagnosis of child abuse could not be confirmed. One case was misinterpreted as normal.

CONCLUSIONS

MRI is the test of choice to rule out child abuse when faced with a child presenting unexplained neurologic signs lasting for few days. The fact that MRI can better differentiate collections of different ages makes this imaging test particularly useful in identifying cases of child abuse. These results, however, always have to be integrated in a well conducted multidisciplinary clinical approach.

Serial radiography in the infant shaken impact syndrome

Certain CT and/or MRI abnormalities have been used medicolegally to time intracranial injuries from the infant shaken impact syndrome (ISIS). For example, parenchymal hypodensities on CT scans are said to arise only after 6-48 h have elapsed postinjury, and the presence of chronic or mixed subdural hematomas suggests injury that occured 1-4 weeks prior. However, these statements are based largely upon inference from data obtained in other conditions such as ischemic anoxic injury and chronic subdural hemorrhage in adults. Direct evidence about the evolution of intracranial injuries in infants with ISIS is sparse, and the radiographic changes following ISIS have never been systematically studied on serial imaging studies. One hundred-seventeen serial CT and MRI scans obtained from 33 infants with ISIS were reviewed retrospectively. The exact scan dates and times were obtained directly from the scans. Acute subdural hemorrhage was the most common intracranial abnormality and was present in 27 (81%) of the 33 infants. Other intracranial abnormalities included chronic subdural collections, subarachnoid hemorrhage, epidural hematomas, parenchymal hypodensities, edema and contusions, and atrophy and encephalomalacia. In 15 of the 33 infants, the injury could be timed with reasonable certainty, and the evolution of the radiographic changes followed over time. Six of the 15 infants had evidence of prior cranial trauma such as chronic subdural collections (5 infants) or mild atrophy (1 infant). Of the remaining 9 infants, parenchymal abnormalities such as hypodensities, edema and contusion appeared in virtually all of the initial scans performed approximately 3 h following the report of injury. One 'chronic' subdural collection was absent on the first scan performed 2.75 h postinjury, but appeared on a second scan performed 17 h later, suggesting that some 'chronic' subdural fluid collections may arise much sooner than previously thought. These findings challenge some of the current dogma about the timing of radiographic changes following abuse and are important in timing the alleged abuse for legal purposes.