Understanding Subdural Collections in Pediatric Abusive Head Trauma

Benign enlargement of the subarachnoid spaces and subdural collections-when to evaluate for abuse

In infants without a history of trauma, subdural haemorrhages should raise the concern for an abusive head injury, particularly when they are associated with bridging vein clotting/rupture or with septations. However, non-haemorrhagic, fluid-appearing subdural collections (also called hygromas) may also be the result of abuse. Subdural collections have also been uncommonly observed in patients with benign enlargement of the subarachnoid spaces (BESS) and a few large-scale studies accurately investigate the incidence and the significance. Currently, there is a wide variation of practices in children with BESS and subdural collections. Due to the social risks associated with abuse evaluation and the perceived risk of radiation exposure, there might be a reluctance to fully evaluate these children in some centres. The diagnosis of physical abuse cannot be substantiated nor safely excluded in infants with BESS and subdural collection(s), without investigation for concomitant traumatic findings. The exact prevalence of occult injuries and abuse in these infants is unknown. In macrocephalic infants with subdural collections and imaging features of BESS, thorough investigations for abuse are warranted and paediatricians should consider performing full skeletal surveys even when fundoscopy, social work consult, and detailed clinical evaluation are unremarkable.

Imaging findings in abusive head trauma (AHT)

Brain imaging plays a key role in accurately identifying abusive head trauma (AHT). An exact and rapid diagnosis is needed due to the extreme severity of AHT, since there is a risk of neurological sequelae and potentially fatal recurrence. Several medical specialists will work collaboratively to detect and confirm abuse in children: the radiologist has a leading role in this approach. This article describes the most common neuro-imaging patterns of AHT, including extra axial, intra axial, bony, and ligamentous lesions, with a special focus on the dating issue and the differential diagnosis.

Non-accidental head injury of infants: legal implications for the pediatric neurosurgeon

BACKGROUND

Though the neurosurgeon's role in non-accidental head injury (NAHT) is the prompt recognition and care of the inflicted injuries, he/she should be aware of the possible legal implications related to this particular neurosurgical condition.

MATERIAL AND METHODS

Based on published data and their own clinical and medico-legal practice, the authors review the role of the neurosurgeon in NHAT.

RESULTS

Besides the contribution that can be given by the neurosurgeon to a correct differential diagnosis, he/she is likely to be involved in the interpretations of the pathological findings in the case where the judge may request for a medical opinion concerning etiology, circumstances, severity, and consequences. As a member of a multidisciplinary team, usually the neurosurgeon is only requested for information regarding the lesions he was called to recognize and treat. Nevertheless, such information may have a pivotal part in the evaluation process. Consequently, the neurosurgeon should be able to reach a correct differential diagnosis of NAHT among all the events that may share similar clinical and anatomo-pathological characteristics and be aware of the ongoing scientific controversies related to the diagnosis and pathophysiology.

CONCLUSIONS

In practical terms, the pediatric neurosurgeon is called to individuate and record all the precise details of the condition to be eventually offered to the judge in case of controversy. Whereas the diagnosis of NAHT should be evoked at the initial phase in order not to leave the child unprotected, all possible alternative hypotheses should be ruled out "beyond reasonable doubt" for the court. The medical file should be maintained in the record carefully and be accessible even after a long time.

Imaging of Abusive Head Trauma : A Radiologists' Perspective

Abusive head trauma (AHT) is the most common and serious form of child abuse and a leading cause of traumatic death in infants and young children. The biomechanics of head injuries include violent shaking, blunt impact, or a combination of both. Neuroimaging plays an important role in recognizing and distinguishing abusive injuries from lesions from accidental trauma or other causes, because clinical presentation and medical history are often nonspecific and ambiguous in this age group. Understanding common imaging features of AHT can increase recognition with high specificity for AHT. In this review, we discuss the biomechanics of AHT, imaging features of AHT, and other conditions that mimic AHT.

Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

Pediatric middle meningeal artery embolization for chronic subdural hematoma: A case report

Background:

The most common neuroradiological finding in pediatric nonaccidental trauma (NAT) is subdural hematoma (SDH). Management options for pediatric SDH range from conservative clinical surveillance to craniotomy or decompressive craniectomy. The middle meningeal artery (MMA) indirectly feeds the hematoma; thus, MMA embolization is an alternative or adjunct to current surgical treatments in adults. Herein, we present, to the best of our knowledge, the first reported case of successful MMA embolization in a pediatric patient as an adjunct to current standard treatment for chronic SDH (cSDH).

Case Description:

An 18-month-old male with a history of NAT presented at 5 months of age with an acute right parietal skull fracture and bilateral SDH treated with burr hole drainage. He was lost to follow-up until 15 months of age with an increased head circumference and new dysconjugate gaze. Imaging revealed a right-sided cSDH and underwent craniotomy. Six-week follow-up revealed significant improvement in the SDH but cSDH remained at the periphery of the craniotomy’s reach. The patient symptoms continued. The right-sided MMA embolization was offered as option to avoid repeat craniotomy. Follow-up CTs at 2 weeks, 3 months, and 6 months postprocedure revealed decrease of cSDH size and density. At 8-month follow-up, the patient continued to meet developmental milestones with near resolution of his dysconjugate gaze.

Conclusion:

This case report details the first successful use of MMA embolization in the treatment of pediatric cSDH as an adjunct to standard treatment. Further investigation of MMA embolization in pediatrics should be made to expand options available for cSDH in this patient population.

Subdural hemorrhage in a cohort with cerebral sinovenous thrombosis: Application to abusive head trauma

BACKGROUND

Cerebral sinovenous thrombosis (CSVT) is a postulated cause of subdural hemorrhage (SDH) that is hypothesized to mimic abusive head trauma (AHT). Minimal data exists directly investigating this relationship.

OBJECTIVES

To evaluate the frequency of SDH in children with CSVT, identify factors associated with CSVT and SDH, and to assess if any association supports the hypothesis that CSVT causes SDH.

PARTICIPANTS AND SETTING

The International Pediatric Stroke Study (IPSS) prospectively collects data on subjects birth to 19 years of age with intracranial thrombosis.

METHODS

IPSS subjects with CSVT and SDH were compared to those with CSVT and no SDH. For subjects with CSVT and SDH, neuroimaging reports further characterized the findings. In any case with no known risk factors for SDH, neuroimaging studies were reviewed by a pediatric neuroradiologist.

RESULTS

Of 216 subjects with CSVT, 20 (9.3%) had SDH. Those with SDH (median age 0.3 years) were younger than those without SDH (median age 4.2 years), p < 0.001. Subjects with CSVT and SDH more frequently had anoxia (OR = 10.8; 95% CI: 1.4, 81.1), head/neck injury (OR = 4.0; 95% CI: 1.3, 12.6), or abnormal consciousness (OR = 3.0; 95% CI: 1.2, 7.6). Of 20 subjects with CSVT and SDH, 19 had known risk factors for SDH. The remaining subject had a chronic SDH identified concomitantly to a newly symptomatic CSVT with accompanying venous infarctions.

CONCLUSIONS

SDH in the setting of CSVT is typically identified in children with independent risk factors for SDH. This study does not support the hypothesis that CSVT causes SDH.

Evolving forensic controversies in child abuse imaging

Child abuse is a common cause of morbidity and mortality in the pediatric population. Despite well-defined evidence establishing bona fide clinical and imaging indicators of child abuse, denialists have emerged on behalf of defendants utilizing unaccepted scientific positions based on literature that they have often authored themselves. This manuscript describes many of the trends in recent legal proceedings while highlighting the importance of consensus statements and professional ethics as they pertain to child abuse imaging. Knowledge of these cases and legal defense strategies is valuable to potential expert witnesses in relevant proceedings.

Macrocephaly and subdural collections

Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.

[Bridging vein injuries in shaken baby syndrome : Forensic-radiological meta-analysis with special focus on the tadpole sign]

Shaken baby syndrome is a common variant of the abusive head trauma in infants and toddlers and is still subject of intensive research. In recent years, a number of radiological studies on the diagnostic and forensic relevance of injured bridging veins were conducted using different imaging modalities. The present article will give an overview on the current state of research in this field and will discuss the forensic implications. The meta-analysis of the seven currently existing studies revealed that injuries of the bridging veins and bridging vein thromboses, respectively, frequently appear as rounded, enlarged, and/or tubular structures. The "tadpole sign" may serve as a valuable tool for the identification of these formations. Especially, T2*/SWI (susceptibility-weighted imaging) sequences allow for good detectability of these lesions and should always be generated when abusive head trauma is suspected. In conclusion, it can be recommended that the presence of radiologically detectable bridging vein injuries should give reason to search for other manifestations of physical child abuse.

Abusive head trauma in court: a multi-center study on criminal proceedings in Germany

The shaken baby syndrome (SBS) is a common variant of abusive head trauma (AHT) in infants and toddlers. Data on the legal outcome of such cases are still sparse. By means of a retrospective multi-center analysis, 72 cases of living children diagnosed with SBS/AHT from three German university institutes of legal medicine were identified. Forty-six of these cases with 68 accused individuals were available and could be evaluated with regard to basic data on the course of the criminal proceedings as well as the profile of the defendants (sub-divided into suspects, convicts, and confessed perpetrators). Criminal proceedings predominantly commenced with a complaint by the treating hospital (62%) and were found to be closed (without judgment) in 50% of the cases, mostly due to a “lack of sufficient suspicion.” Of the 23 cases with judgment, the court decided on acquittal in 4 cases (17%). Imprisonment was the most frequent sentence (16 out of 19 cases with conviction, 84%), whereby the sentence has been suspended on probation in 63% of the cases. Suspects and perpetrators were mostly male and derived from the close family environment of the injured children. All confessed perpetrators stated an “excessive demand” as the reason for the violent shaking of the child. The results of the present study are in line with data from other studies with other legal systems. As many criminal proceedings were closed and the 4 acquittals occurred because the perpetration could not be ascribed to a specific perpetrator, improving the forensic methods for such an unequivocal assignment would be desirable.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

AIM

Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants.

METHODS

Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature.

RESULTS

Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children.

CONCLUSION

Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.

Updating the risk profile of fatal head trauma: an autopsy study with focus on age- and sex-dependent differences

Fatal head trauma (FHT) represents one of the most frequent causes of death diagnosed in forensic pathology. However, profound statistic autopsy data on FHT is still sparse. Therefore, the purpose of this study was to investigate the circumstances and injury patterns of FHT with particular focus on age and sex, and additionally, to describe a recent risk profile of FHT. To this end, the forensic autopsy records of each FHT case at a large German university hospital during a 10-year period (2006-2015) were analyzed retrospectively (n = 372). The male-female ratio was 2.6:1. Regarding median age, females were 12.5 years older than males. Traffic-associated FHT represents the major mechanism of death, followed by fall-associated FHT. While accident was the major manner of death and presented a similar distribution of age and sex, homicides were the only subgroup with a significantly lower ratio between males and females. Skull fractures occurred in 78.2% and intracranial hemorrhages in 80.6% of all cases. In summary and partly in contrast to clinical data on head trauma, FHT still occurs predominantly in male individuals under the age of 45 years, in the context of traffic accidents and affected by alcohol intake. Improvements in traffic security as well as continuing surveillance of the incidence of FHT by forensic autopsies are necessary to further reduce the incidence of FHT.