1
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Mankad K, Sidpra J, Mirsky DM, Oates AJ, Colleran GC, Lucato LT, Kan E, Kilborn T, Agrawal N, Teeuw AH, Kelly P, Zeitlin D, Carter J, Debelle GD, Berger RP, Christian CW, Lindberg DM, Raissaki M, Argyropoulou M, Adamsbaum C, Cain T, van Rijn RR, Silvera VM, Rossi A, Kemp AM, Choudhary AK, Offiah AC. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. JAMA Pediatr 2023; 177:526-533. [PMID: 36877504 DOI: 10.1001/jamapediatrics.2022.6184] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Importance Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. Objective To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. Evidence Review This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. Findings Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. Conclusions and Relevance This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.
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Affiliation(s)
- Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jai Sidpra
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David M Mirsky
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Adam J Oates
- Department of Radiology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Gabrielle C Colleran
- Department Radiology, Children's Health Ireland and The National Maternity Hospital, Dublin, Ireland
| | - Leandro T Lucato
- Department of Radiology, Universidade de São Paulo, Faculdade de Medicina, São Paulo, Brazil
| | - Elaine Kan
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong
| | - Tracy Kilborn
- Department of Radiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Nina Agrawal
- City University of New York Graduate School of Public Health and Health Policy, New York
| | - Arianne H Teeuw
- Department of Pediatrics, Emma Children's Hospital-Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick Kelly
- Te Puaruruhau, Starship Children's Health, Auckland, New Zealand
- Department of Pediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Deborah Zeitlin
- Department of Pediatrics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jamieson Carter
- Department of Pediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Geoff D Debelle
- Department of Pediatrics, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cindy W Christian
- Department of Pediatrics, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Maria Raissaki
- Department of Radiology and Imaging, University Hospital of Heraklion, Medical School, University of Crete, Rethymno, Greece
| | - Maria Argyropoulou
- Department of Clinical Radiology, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Catherine Adamsbaum
- Paris Saclay University, Faculty of Medicine, AP-HP, Bicêtre Hospital, Department of Paediatric Radiology, Le Kremlin Bicêtre, France
| | - Timothy Cain
- Department of Medical Imaging, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital-Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, the Netherlands
| | | | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Alison M Kemp
- Division of Population Medicine, Department of Child Health, University of Cardiff, Cardiff, United Kingdom
| | - Arabinda K Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock
| | - Amaka C Offiah
- Department of Radiology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, United Kingdom
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
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2
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Abstract
In this article, we describe relevant anatomy, mechanisms of injury, and imaging findings of abusive head trauma (AHT). We also briefly address certain mimics of AHT, controversies, pearls, and pitfalls. Concepts of injury, its evolution, and complex nature of certain cases are highlighted with the help of case vignettes.
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Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada; Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK.
| | - Pradeep Krishnan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
| | - Ibrahem Albalkhi
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; College of Medicine, Alfaisal University, Al Takhassousi، Al Zahrawi Street interconnecting with, Riyadh 11533, Saudi Arabia
| | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N3JH, UK; UCL GOS Institute of Child Health
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada; Department of Medical Imaging, University of Toronto, Ontario, Canada
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3
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Paddock M, Choudhary AK, Jeanes A, Mankad K, Mannes I, Raissaki M, Adamsbaum C, Argyropoulou MI, van Rijn RR, Offiah AC. Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce. Pediatr Radiol 2023; 53:739-751. [PMID: 36879046 PMCID: PMC10027646 DOI: 10.1007/s00247-023-05618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 03/08/2023]
Abstract
This second roundtable discussion was convened at the 56th European Society of Paediatric Radiology (ESPR) 2022 Annual Meeting in Marseille, France, to discuss controversial aspects of imaging in child abuse. The following topics were discussed: Fracture dating-the published literature is broadly similar with respect to the identification of the radiographic stages of bony healing. The non-expert/general radiologist is encouraged to use broad descriptors of fracture healing (acute, healing or old) within their reports, rather than attempting to date fractures. The more experienced/expert radiologist, who may provide a timeframe/range to assist the courts, should be aware that any published timeframes are not absolute and that recent research indicates that the rate of healing may differ according to the bone affected and the age of the patient. Whole spine imaging in suspected abusive head trauma-this is recommended to enable a complete assessment of the neuraxis when abusive head trauma is suspected or diagnosed, particularly in the presence of intracranial and cervical subdural haemorrhage and cervical ligamentous injury. Cranial imaging in suspected physical abuse-both computed tomography (CT) and magnetic resonance imaging (MRI) remain complimentary depending on the clinical context in which they are used with CT remaining first-line in the assessment of children with (suspected abusive) head trauma prior to an early MRI. MRI is superior in its assessment of parenchymal injury and may be employed as first-line in age appropriate asymptomatic siblings of a child with suspected physical abuse.
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Affiliation(s)
- Michael Paddock
- Medical Imaging Department, Perth Children's Hospital, Perth, WA, Australia.
- Division of Paediatrics, University of Western Australia, Perth, WA, Australia.
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK.
| | - Arabinda K Choudhary
- Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Inès Mannes
- Paediatric Radiology Department, AP-HP, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France
| | - Maria Raissaki
- Radiology Department, Medical School, University Hospital of Heraklion, University of Crete, Crete, Greece
| | - Catherine Adamsbaum
- Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, Paris, France
| | - Maria I Argyropoulou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - Rick R van Rijn
- Department of Radiology and Nuclear Medicine, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Amaka C Offiah
- Department of Oncology & Metabolism, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield, UK
- Department of Radiology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Wiskott K, Gilardi F, Hainard A, Sanchez JC, Thomas A, Sajic T, Fracasso T. Blood proteome of acute intracranial hemorrhage in infant victims of abusive head trauma. Proteomics 2023; 23:e2200078. [PMID: 36576318 DOI: 10.1002/pmic.202200078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022]
Abstract
Abusive head trauma (AHT) is a leading cause of mortality and morbidity in infants. While the reported incidence is close to 40 cases per 100'000 births/year, misdiagnoses are commonly observed in cases with atypical, subacute, or chronic presentation. Currently, standard clinical evaluation of inflicted intracranial hemorrhagic injury (ICH) in infants urgently requires a screening test able to identify infants who need additional investigations. Blood biomarkers characteristic of AHT may assist in detecting these infants, improving prognosis through early medical care. To date, the application of innovative omics technologies in retrospective studies of AHT in infants is rare, due also to the blood serum and cerebrospinal fluid of AHT cases being scarce and not systematically accessible. Here, we explored the circulating blood proteomes of infants with severe AHT and their atraumatic controls. We discovered 165 circulating serum proteins that display differential changes in AHT cases compared with atraumatic controls. The peripheral blood proteomes of pediatric AHT commonly reflect: (i) potentially secreted proteome from injured brain, and (ii) proteome dysregulated in the system's circulation by successive biological events following acute ICH. This study opens up a novel opportunity for research efforts in clinical screening of AHT cases.
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Affiliation(s)
- Kim Wiskott
- Forensic medicine unit, University Center of Legal Medicine, Geneva 4, Switzerland
| | - Federica Gilardi
- Faculty Unit of Toxicology, University Center of Legal Medicine, Lausanne University Hospital, Lausanne 25, Switzerland.,Unit of Forensic Toxicology and Chemistry, CURML, Lausanne University Hospital and Geneva University Hospital, Geneva, Switzerland
| | - Alexandre Hainard
- Proteomics Core Facility, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Charles Sanchez
- Translational Biomarker Group, Department of Internal Medicine, University of Geneva, Geneva, Switzerland
| | - Aurelien Thomas
- Faculty Unit of Toxicology, University Center of Legal Medicine, Lausanne University Hospital, Lausanne 25, Switzerland.,Unit of Forensic Toxicology and Chemistry, CURML, Lausanne University Hospital and Geneva University Hospital, Geneva, Switzerland
| | - Tatjana Sajic
- Faculty Unit of Toxicology, University Center of Legal Medicine, Lausanne University Hospital, Lausanne 25, Switzerland.,Unit of Forensic Toxicology and Chemistry, CURML, Lausanne University Hospital and Geneva University Hospital, Geneva, Switzerland
| | - Tony Fracasso
- Forensic medicine unit, University Center of Legal Medicine, Geneva 4, Switzerland
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Canty KW, Feldman KW, Bartnik-Olson B, Choudhary AK, Shiroishi MS; ENIGMA Child Abuse Working Group. Current issues and controversies surrounding spine imaging and the significance of spinal subdural hemorrhage in suspected abusive head trauma. Pediatr Radiol 2022; 52:2445-9. [PMID: 36261511 DOI: 10.1007/s00247-022-05534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/17/2022] [Accepted: 10/10/2022] [Indexed: 10/24/2022]
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6
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Lee SG, Whang K, Cho SM, Jang YG, Kim J, Choi J. Factors Associated With Subdural Hygroma Following Mild Traumatic Brain Injury. Korean J Neurotrauma 2022; 18:230-237. [PMCID: PMC9634298 DOI: 10.13004/kjnt.2022.18.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Subdural hygroma (SDG) is a complication of traumatic brain injury (TBI). In particular, the outcome and outpatient treatment period may vary depending on the occurrence of SDG. However, the pathogenesis of SDG has not been fully elucidated. Therefore, this study aimed to identify the risk factors associated with the occurrence of SDG after mild TBI. Methods We retrospectively analyzed 250 patients with mild TBI admitted to a single institution between January 2021 and December 2021. The SDG occurrence and control groups were analyzed according to the risk factors of SDG, such as age, history, initial computed tomography (CT) findings, and initial laboratory findings. Results The overall occurrence rate of SDG was 31.6% (n=79). A statistically significant association was found between preoperative diagnoses and the occurrence of SDG, such as subarachnoid hemorrhage (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.26–4.39) and basal skull fracture (OR, 0.32; 95% CI, 0.12–0.83). Additionally, age ≥70 years (OR, 3.20; 95% CI, 1.74–5.87) and the use of tranexamic acid (OR, 2.12; 95% CI, 1.05–4.54) were statistically significant factors. The prognostic evaluation of patients using the Glasgow Outcome Scale (GOS) did not show any statistical differences between patients with and without SDG. Conclusion SDG was not associated with the prognosis of patients assessed using the GOS. However, depending on the occurrence of SDG, differences in patient symptoms may occur after mild TBI. Therefore, the early evaluation of patients with mild TBI and determination of the probability of developing SDG are important.
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Affiliation(s)
- Sang-Geun Lee
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Min Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Gyu Jang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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7
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Adamsbaum C, Coutellec L. Le syndrome du bébé secoué (SBS), l’enjeu de la fiabilité face à la fabrique de l’ignorance. Bulletin de l'Académie Nationale de Médecine 2022. [DOI: 10.1016/j.banm.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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8
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Abstract
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.
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Affiliation(s)
- Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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9
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Caré MM. Parenchymal Insults in Abuse—A Potential Key to Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12040955. [PMID: 35454003 PMCID: PMC9029348 DOI: 10.3390/diagnostics12040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.
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Affiliation(s)
- Marguerite M. Caré
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology and Medical Imaging, University of Cincinnati, Cincinnati, OH 45267, USA
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10
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Karmazyn B, Reher TA, Supakul N, Streicher DA, Kiros N, Diggins N, Jennings SG, Eckert GJ, Hibbard RA, Radhakrishnan R. Whole spine MRI in children with suspected child abuse. AJR Am J Roentgenol 2022. [PMID: 35018794 DOI: 10.2214/AJR.21.26674] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Abusive head trauma (AHT) in children has recently been associated with findings on cervical spine MRI. Objective: To evaluate whether whole-spine MRI in children suspected of AHT shows additional abnormalities not identified on cervical spine MRI. Methods: This retrospective study included 256 children young than 3 years (170 boys, 86 girls; mean age, 5.9 months) who underwent skeletal survey and head MRI for suspected child abuse from January 2019 to December 2020. Per institutional protocol, children with suspected AHT also underwent whole-spine MRI. AHT diagnoses were established by combination of clinical information from medical record review and injuries described in reports from skeletal survey, head MRI, and head CT (if performed). Two pediatric neuroradiologists independently reviewed whole-spine MRI examinations for presence and level of intraspinal hemorrhage (classified as subarachnoid, subdural, or epidural), ligamentous injury, spinal cord edema, and vertebral fractures; subdural hematoma, epidural hematoma, ligamentous injury, and fracture unidentified by skeletal survey were considered major findings. Interreader agreement was assessed; a third radiologist resolved discrepancies. Findings were summarized with attention to injuries isolated to the thoracolumbar spine. Results: A total of 148/256 (57.8%) children underwent whole-spine MRI. AHT was diagnosed in 79/148 (53.4%) children who underwent whole-spine MRI, versus in 2/108 (1.9%) who did not undergo whole-spine MRI (p<.001). Interobserver agreement. expressed as kappa, was 0.90 for intraspinal hemorrhage, 0.69 for ligamentous injury, 0.66 for spinal cord edema, and 0.95 for fracture. A total of 57/148 (38.5%) whole-spine MRI examinations demonstrated injuries; 34/148 (23.0%) demonstrated injuries localized to the thoracolumbar spine. A total of 47/148 (31.8%) whole-spine MRI examinations demonstrated major findings, of which 24/47 (51.1%) were localized to the thoracolumbar spine. Isolated thoracolumbar injuries included 23 of 34 subdural hematomas, 2 of 3 epidural hematomas, and 9 of 11 fractures, including 5 fractures not identified by skeletal survey. Diagnosis of AHT was more common in children with positive, versus negative, whole-spine MRI examinations (76.8% vs 39.1%, p<.001). Conclusion: In children with suspected AHT, whole-spine MRI commonly demonstrates isolated thoracolumbar injuries. Clinical Impact: The results support performing whole-spine MRI rather than cervical spine MRI in children with suspected AHT.
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11
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van Rijn RR, Robben SGF, Fronczek J, Klein WM. Child Abuse, a Post-mortem Forensic Perspective. Forensic Imaging 2022. [DOI: 10.1007/978-3-030-83352-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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12
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Pendharkar H, Jabeen S, Pruthi N, Narasinga Rao KVLN, Shukla D, Kamble N, Jangam KV, Kommu JVS, Kandavel T, Amudhan S. Abusive head trauma in India: imaging raises the curtain. Int J Inj Contr Saf Promot 2021; 29:103-111. [PMID: 34913839 DOI: 10.1080/17457300.2021.2007955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.
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Affiliation(s)
- Hima Pendharkar
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Shumyla Jabeen
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - K V L N Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Nitish Kamble
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Kavita V Jangam
- Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - John Vijay Sagar Kommu
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Thennarasu Kandavel
- Department of Biostatistics, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Senthil Amudhan
- Department of Epidemiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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Garcia-Pires F, Jayappa S, Desai S, Ramakrishnaiah RH, Choudhary AK. Spinal subdural hemorrhage in abusive head trauma: a pictorial review. Pediatr Radiol 2021; 51:980-990. [PMID: 33999240 DOI: 10.1007/s00247-020-04931-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/27/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
A growing body of evidence links abusive head trauma (AHT) to patterns of direct and indirect spinal injuries, such as spinal subdural hemorrhage (SDH). Identification of evidence of spinal injury such as spinal SDH plays a crucial role in the diagnosis and subsequent management of the index child with AHT and his or her siblings. In a value-based practice of medicine, it can be argued that adding spine imaging to identify spinal SDH in the workup of AHT adds value to both the short- and long-term management of the patient. This pictorial review describes the normal appearance of spinal SDH and challenges of identifying spinal SDH, and it explores the mechanism of spinal SDH development in AHT.
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Affiliation(s)
- Flavio Garcia-Pires
- Department of Radiology, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA.
| | - Sateesh Jayappa
- Department of Radiology, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Shivang Desai
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raghu H Ramakrishnaiah
- Department of Radiology, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Arabinda K Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences (UAMS), 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Kim BM, Chang MY, Lee SH, Ha JW. Spinal subdural hematoma: A report of 3 cases related to antiplatelet agent use and traumatic compression fracture. Radiol Case Rep 2021; 16:1454-8. [PMID: 33912263 DOI: 10.1016/j.radcr.2021.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 12/02/2022] Open
Abstract
Spinal subdural hematoma is a rare condition presenting with symptoms of back pain and neurologic deficits. The etiology is largely idiopathic, followed by anti–coagulant use and vascular malformation. Traumatic subdural hematomas associated with compression fractures are rare, with only a few old case reports. Magnetic resonance imaging is the modality of choice for the diagnosis of spinal subdural hematoma. Treatment is surgical decompression when neurologic deficits exist; however, conservative management is a good option in patients without neurologic symptoms with reported spontaneous hematoma regression. Herein, we report 3 cases of spinal subdural hematoma, 2 spontaneous cases related to anti–platelet agent use and 1 with acute traumatic compression fracture. T1-weighted fat-saturated images clearly showed the hematoma and increased the confidence level of the diagnosis. In summary, we suggest that magnetic resonance imaging can clearly visualize the spinal subdural hematoma and is excellent for diagnosis and follow up. Anti–platelet agent use and compression fracture are probable etiologies of spinal subdural hematoma.
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16
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Colombari M, Troakes C, Turrina S, Tagliaro F, De Leo D, Al-Sarraj S. Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT). Int J Legal Med 2021; 135:1481-1498. [PMID: 33619608 PMCID: PMC8205921 DOI: 10.1007/s00414-021-02526-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological “triad”, a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216–223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44–48% when all the spinal cord levels are analysed as opposed to just 0–18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.
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Affiliation(s)
- Michela Colombari
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy.
| | - Claire Troakes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Stefania Turrina
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy
| | - Franco Tagliaro
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy.,Institute of Translational Medicine and Biotechnology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Domenico De Leo
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, Verona, Italy
| | - Safa Al-Sarraj
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Department of Clinical Neuropathology, King's College Hospital NHS Foundation Trust, London, UK
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17
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Cartocci G, Fineschi V, Padovano M, Scopetti M, Rossi-Espagnet MC, Giannì C. Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma. Brain Sci 2021; 11:179. [PMID: 33535601 DOI: 10.3390/brainsci11020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/10/2023] Open
Abstract
In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration–deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice.
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18
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Henry MK, French B, Feudtner C, Zonfrillo MR, Lindberg DM, Anderst JD, Berger RP, Wood JN. Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury. Pediatr Emerg Care 2021; 37:e1-e6. [PMID: 29461428 PMCID: PMC6093798 DOI: 10.1097/pec.0000000000001455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI). METHODS We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified. RESULTS Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries. CONCLUSIONS Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.
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Affiliation(s)
- M. Katherine Henry
- Division of General Pediatrics, The Children's Hospital of Philadelphia, 34 Street and Civic Center Boulevard, Philadelphia, PA 19104
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South St, Philadelphia, PA 19146, USA
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 204 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
| | - Chris Feudtner
- Division of General Pediatrics, The Children's Hospital of Philadelphia, 34 Street and Civic Center Boulevard, Philadelphia, PA 19104
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South St, Philadelphia, PA 19146, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34 Street and Civic Center Boulevard, Philadelphia, PA 19104
| | - Mark R. Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Alpert Medical School of Brown University and Hasbro Children's Hospital, 55 Claverick Street, 2 Floor, Providence, RI 02903
| | - Daniel M. Lindberg
- Department of Emergency Medicine and The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect. University of Colorado School of Medicine. 12401 E. 17 Ave. Aurora, CO 80238
| | - James D. Anderst
- Department of Pediatrics, Division of Child Abuse and Neglect, University of Missouri Kansas City School of Medicine and Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108
| | - Rachel P. Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, 2nd Floor, Pittsburgh, PA 15224
| | - Joanne N. Wood
- Division of General Pediatrics, The Children's Hospital of Philadelphia, 34 Street and Civic Center Boulevard, Philadelphia, PA 19104
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South St, Philadelphia, PA 19146, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34 Street and Civic Center Boulevard, Philadelphia, PA 19104
- PolicyLab, The Children's Hospital of Philadelphia, 2716 South St, Philadelphia, PA 19146, USA
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19
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Kazmir S, Rosado N. Abusive Head Trauma: A Review of Current Knowledge. Clinical Pediatric Emergency Medicine 2020. [DOI: 10.1016/j.cpem.2020.100791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Abstract
Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.
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Affiliation(s)
- Sandeep K Narang
- Division of Child Abuse Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - Amanda Fingarson
- Division of Child Abuse Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
| | - James Lukefahr
- Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
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21
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Hong CS, Camara-Quintana J, Kundishora AJ, Diluna ML, Kahle KT. Teaching NeuroImages: Spinal subdural hematoma in pediatric nonaccidental trauma. Neurology 2020; 93:e522-e523. [PMID: 31358679 DOI: 10.1212/wnl.0000000000007869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Christopher S Hong
- From the Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Adam J Kundishora
- From the Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Michael L Diluna
- From the Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Kristopher T Kahle
- From the Department of Neurosurgery, Yale University School of Medicine, New Haven, CT.
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22
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Rabbitt AL, Kelly TG, Yan K, Zhang J, Bretl DA, Quijano CV. Characteristics associated with spine injury on magnetic resonance imaging in children evaluated for abusive head trauma. Pediatr Radiol 2020; 50:83-97. [PMID: 31901991 DOI: 10.1007/s00247-019-04517-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/24/2019] [Accepted: 08/28/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spine injuries are increasingly common in the evaluation for abusive head trauma (AHT), but additional information is needed to explore the utility of spine MRI in AHT evaluations and to ensure an accurate understanding of injury mechanism. OBJECTIVE To assess the incidence of spine injury on MRI in children evaluated for AHT, and to correlate spine MRI findings with clinical characteristics. MATERIALS AND METHODS We identified children younger than 5 years who were evaluated for AHT with spine MRI. Abuse likelihood was determined a priori by expert consensus. We blindly reviewed spine MRIs and compared spinal injury, abuse likelihood, patient demographics, severity of brain injury, presence of retinal hemorrhages, and pattern of head injury between children with and without spine injury. RESULTS Forty-five of 76 (59.2%) children had spine injury. Spine injury was associated with more severe injury (longer intensive care stays [P<0.001], lower initial mental status [P=0.01] and longer ventilation times [P=0.001]). Overall abuse likelihood and spine injury were not associated. Spinal subdural hemorrhage was the only finding associated with a combination of retinal hemorrhages (P=0.01), noncontact head injuries (P=0.008) and a diagnosis of AHT (P<0.05). Spinal subdural hemorrhage was associated with other spine injury (P=0.004) but not with intracranial hemorrhage (P=0.28). CONCLUSION Spinal injury is seen in most children evaluated for AHT and might be clinically and forensically valuable. Spinal subdural hemorrhage might support a mechanism of severe acceleration/deceleration head injury and a diagnosis of AHT.
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23
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Affiliation(s)
- Arabinda K Choudhary
- Department of Radiology, University of Arkansas Medical Sciences, 4301 W. Markham, Little Rock, AR, 72223, USA.
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24
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Orman G, Kralik SF, Meoded A, Desai N, Risen S, Huisman TAGM. MRI Findings in Pediatric Abusive Head Trauma: A Review. J Neuroimaging 2019; 30:15-27. [PMID: 31696594 DOI: 10.1111/jon.12670] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/04/2019] [Accepted: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
Trauma is the most common cause of death and significant morbidity in childhood; abusive head trauma (AHT) is a prominent cause of significant morbidity and mortality in children younger than 2 years old. Correctly diagnosing AHT is challenging both clinically and radiologically. The primary diagnostic challenges are that the abused children are usually too young to provide an adequate history, perpetrators are unlikely to provide truthful account of trauma, and clinicians may be biased in their assessment of potentially abused children. The main radiological challenge is that there is no single imaging finding that is independently specific for or diagnostic of AHT. The radiological evaluation should be based on the multiplicity and severity of findings and an inconsistency with the provided mechanism of trauma. While the most common neuroimaging finding in AHT is subdural hemorrhage, other less well-known magnetic resonance imaging (MRI) findings such as the "lollipop sign" or "tadpole sign," parenchymal or cortical lacerations, subpial hemorrhage, cranio-cervical junction injuries including retroclival hematomas, as well as diffuse hypoxic brain injury have been identified and described in the recent literature. While AHT is ultimately a clinical diagnosis combining history, exam, and neuroimaging, familiarity with the typical as well as the less-well known MRI findings will improve recognition of AHT by radiologists.
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Affiliation(s)
- Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Nilesh Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital
| | - Sarah Risen
- Department of Pediatrics, Section of Neurology and Developmental Neuroscience, Baylor College of Medicine at Texas Children's Hospital, Houston, TX
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25
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Derderian SC, Greenan K, Mirsky DM, Stence NV, Graber S, Hankinson TC, Hubbell N, Alexander A, O'neill BR, Wilkinson CC, Handler MH. The utility of magnetic resonance imaging in pediatric trauma patients suspected of having cervical spine injuries. J Trauma Acute Care Surg 2019; 87:1328-35. [DOI: 10.1097/ta.0000000000002487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Affiliation(s)
- Aaron S. McAllister
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
| | - Usha Nagaraj
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
| | - Rupa Radhakrishnan
- From the Department of Radiology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205, and Department of Radiology, The Ohio State University, Columbus, Ohio (A.S.M.); Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital, Cincinnati, Ohio (U.N.); and Department of Radiology and Imaging Sciences, Riley Hospital for Children at Indiana University Health, Indianapolis, Ind (R.R.)
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27
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Gunda D, Cornwell BO, Dahmoush HM, Jazbeh S, Alleman AM. Pediatric Central Nervous System Imaging of Nonaccidental Trauma: Beyond Subdural Hematomas. Radiographics 2019; 39:213-228. [DOI: 10.1148/rg.2019180084] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Divya Gunda
- From the Department of Radiological Sciences, University of Oklahoma Health Sciences Center, PO Box 26901, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126 (D.G., B.O.C., S.J., A.M.A.); and Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (H.M.D.)
| | - Benjamin O. Cornwell
- From the Department of Radiological Sciences, University of Oklahoma Health Sciences Center, PO Box 26901, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126 (D.G., B.O.C., S.J., A.M.A.); and Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (H.M.D.)
| | - Hisham M. Dahmoush
- From the Department of Radiological Sciences, University of Oklahoma Health Sciences Center, PO Box 26901, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126 (D.G., B.O.C., S.J., A.M.A.); and Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (H.M.D.)
| | - Sammer Jazbeh
- From the Department of Radiological Sciences, University of Oklahoma Health Sciences Center, PO Box 26901, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126 (D.G., B.O.C., S.J., A.M.A.); and Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (H.M.D.)
| | - Anthony M. Alleman
- From the Department of Radiological Sciences, University of Oklahoma Health Sciences Center, PO Box 26901, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126 (D.G., B.O.C., S.J., A.M.A.); and Department of Radiology, Stanford University School of Medicine, Palo Alto, Calif (H.M.D.)
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28
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Abstract
Acute onset of neurological signs and symptoms referable to the spine including difficulty walking, bowel and bladder dysfunction, and paresthesias in the extremities may be manifestations of pediatric spine emergency. Trauma is the most common etiology for a pediatric spinal emergency. Because a history of trauma is often available, the role of imaging involves detection of spinal injuries. Other pathologies such as infection, inflammation, vascular, and neoplasms may lead to pediatric spinal emergencies that also require imaging for assistance in determining the etiology and appropriate management.
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Affiliation(s)
- Katie Suzanne Traylor
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Stephen F Kralik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202.
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29
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Abstract
Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.
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Affiliation(s)
- Sara Reis Teixeira
- Division of Radiology, Clinical Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto
| | | | - Carolina A Servin
- Centro Medico La Costa - Centro de Diagnóstico, Av General José Gervasio Artigas, Asunción, Paraguay
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, UK
| | - Giulio Zuccoli
- Professor of Radiology, University of Pittsburgh School of Medicine, Director of Pediatric Neuroradiology, Children Hospital of Pittsburgh, Pittsburgh, PA
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30
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Wittschieber D, Kinner S, Pfeiffer H, Karger B, Hahnemann ML. Forensische Aspekte bildgebender Verfahren bei Schütteltrauma-Syndrom: Methodik, Befunde, Differenzialdiagnosen. Rechtsmedizin (Berl) 2018; 28:486-94. [DOI: 10.1007/s00194-018-0274-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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31
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Abstract
Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.
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Affiliation(s)
- Jennifer K Lee
- From the *Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, Baltimore, Maryland; †Department of Pediatrics, Anesthesia, and Critical Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and ‡Departments of Anesthesiology and Pediatrics, Children's National Health System, Washington DC
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Booth TN, Jacob R, Greenwell C, Reeder K, Koral K. Reply. AJNR Am J Neuroradiol 2017; 38:E31. [PMID: 28209584 DOI: 10.3174/ajnr.a5111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- T N Booth
- Children's Health Dallas University of Texas Southwestern Medical Center Dallas, Texas
| | - R Jacob
- University Medical Center Health System Texas Tech University Lubbock, Texas
| | - C Greenwell
- Children's Health Dallas University of Texas Southwestern Medical Center Dallas, Texas
| | - K Reeder
- Children's Health Dallas University of Texas Southwestern Medical Center Dallas, Texas
| | - K Koral
- Children's Health Dallas University of Texas Southwestern Medical Center Dallas, Texas
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Paddock M, Sprigg A, Offiah A. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses. Clin Radiol 2017; 72:189-201. [DOI: 10.1016/j.crad.2016.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 11/08/2016] [Accepted: 11/21/2016] [Indexed: 11/16/2022]
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Rangwala SD, Birk DM, Tobin MK, Hahn YS, Nikas DC. Spontaneous Resolution of Spinal Epidural Hematoma Resulting from Domestic Child Abuse: Case Report. Pediatr Neurosurg 2017; 52:51-54. [PMID: 27644085 DOI: 10.1159/000448737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/27/2016] [Indexed: 11/19/2022]
Abstract
Nonaccidental head injury, as seen in domestic child abuse cases, is often associated with spinal injury, and spinal subdural hematoma is the most frequent diagnosis. While spinal epidural hematomas are a rare occurrence, the incidence of spontaneous epidural hematomas occurring in nonaccidental head injury patients is even lower. Epidural hematomas often result in acute focal neurological deficits necessitating emergent neurosurgical intervention. In patients without focal neurological deficits, conservative management may allow for spontaneous resolution of the epidural hematoma. The authors present the case of a 2-year-old boy with a large spinal epidural hematoma resulting after an event of nonaccidental injury, specifically, domestic child abuse. This patient exhibited no focal neurological deficits and was managed conservatively without surgical clot evacuation. On a follow-up visit, repeat imaging studies demonstrated a stable resolution of spinal epidural hematoma, providing further support for the safety of conservative management in these patients.
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Affiliation(s)
- Shivani D Rangwala
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Ill., USA
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Pfeifer CM, Hammer MR, Mangona KL, Booth TN. Non-accidental trauma: the role of radiology. Emerg Radiol 2016; 24:207-213. [DOI: 10.1007/s10140-016-1453-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
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Jacob R, Cox M, Koral K, Greenwell C, Xi Y, Vinson L, Reeder K, Weprin B, Huang R, Booth TN. MR Imaging of the Cervical Spine in Nonaccidental Trauma: A Tertiary Institution Experience. AJNR Am J Neuroradiol 2016; 37:1944-1950. [PMID: 27231224 DOI: 10.3174/ajnr.a4817] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/21/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cervical MR imaging has demonstrated a utility for detecting soft tissue injury in nonaccidental trauma. The purpose of this study was to identify the incidence and types of cervical spine injury on MR imaging in nonaccidental trauma and to correlate cervical spine injury with parenchymal injury on brain MR imaging and findings on head CT. MATERIALS AND METHODS A retrospective review of children diagnosed with nonaccidental trauma in a tertiary referral pediatric hospital over 8 years was performed. Inclusion criteria were children younger than 5 years of age, a confirmed diagnosis of nonaccidental trauma, and cervical spine MR imaging within 1 week of presentation. Brain and cervical spine MR imaging, head CT, cervical radiographs, and skeletal surveys were reviewed. RESULTS There were 89 patients included in this study (48 males; mean age, 9.1 months [range, 1-59 months]). Cervical spine injury on MR imaging was found in 61 patients (69%). Ligamentous injury was seen in 60 patients (67%), with interspinous ligaments being most commonly involved. Abnormal capsular fluid (atlanto-occipital and atlantoaxial) was present in 28 patients (32%). Cervical spine injury on MR imaging was significantly associated with parenchymal restricted diffusion on brain MR imaging and parenchymal injury on head CT (P = .0004 and P = .0104, respectively). Children with restricted diffusion on brain MR imaging were 6.22 (point estimate) times more likely to have cervical spine injury on MR imaging. CONCLUSIONS There is a high incidence of cervical spine injury in pediatric nonaccidental trauma. Positive findings may affect management and suggest a traumatic etiology.
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Affiliation(s)
- R Jacob
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | - M Cox
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - K Koral
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | | | - Y Xi
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
| | | | - K Reeder
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - B Weprin
- Pediatrics (M.C., K.R., B.W., R.H.).,Neurological Surgery (B.W.), Children's Health, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R Huang
- Pediatrics (M.C., K.R., B.W., R.H.)
| | - T N Booth
- From the Departments of Radiology (R.J., K.K., Y.X., T.N.B.)
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Delgado Álvarez I, de la Torre IBM, Vázquez Méndez É. The radiologist's role in child abuse: imaging protocol and differential diagnosis. Radiologia 2016; 58 Suppl 2:119-28. [PMID: 27091551 DOI: 10.1016/j.rx.2016.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 11/19/2022]
Abstract
Child abuse or nonaccidental trauma is a major problem worldwide; in Spain, there are about 12,000 victims per year. The detection of specific lesions or findings that are incongruent with the reported mechanism of trauma mean that radiologists are often the physician responsible for sounding the alarm in cases of abuse. The triad consisting of subdural hematoma, metaphyseal fracture, and posterior rib fractures is very characteristic of the battered child syndrome. The finding of acute and chronic lesions in the same patient is highly specific for nonaccidental trauma. Fractures of long bones in patients who have yet begun to walk should also alert to possible child abuse. Lesions that are highly specific for abuse, such as classic metaphyseal fractures or posterior rib fractures, can be difficult to demonstrate radiographically and are usually clinically occult. The American College of Radiology (ACR) protocols recommend obtaining three separate X-rays of each upper and lower limb. It is important to use X-ray systems that give high resolution images with low kilovoltage (50-70 kvp) and appropriate milliamperage. A skeletal survey consisting of a series of images collimated to each body region is recommended for all children under the age of two years in whom abuse is suspected. A follow-up skeletal survey about two weeks after the initial survey is useful for detecting new fractures and for assessing the consolidation of others, which helps in dating the lesions. Head injuries are the leading cause of death in abused children. Although computed tomography is the first neuroimaging technique in nonaccidental trauma, magnetic resonance imaging of the head can better characterize the lesions seen on computed tomography and can help to estimate the age of the lesions.
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Affiliation(s)
- I Delgado Álvarez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España.
| | | | - É Vázquez Méndez
- Departamento de Radiología Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España
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Affiliation(s)
- Jill C Glick
- Department of Pediatrics, University of Chicago; Medical Director, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
| | - Michele A Lorand
- Division of Child Protective Services, Department of Pediatrics; Medical Director, Chicago Children's Advocacy Center, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
| | - Kristen R Bilka
- Department of Pediatrics, University of Chicago; Physician Assistant, Child Advocacy and Protective Services, University of Chicago Comer Children's Hospital, Chicago, IL
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Affiliation(s)
- Amit Agarwal
- Department of Radiology, Penn State University Hershey Medical Center, Hershey, Pennsylvania.
| | - Krishnamurthy Thamburaj
- Department of Radiology, Penn State University Hershey Medical Center, Hershey, Pennsylvania
| | - Sangam Kanekar
- Department of Radiology, Penn State University Hershey Medical Center, Hershey, Pennsylvania
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Agrawal H, Dokania G, Severin PN. New-Onset Seizures in an Infant. Pediatr Ann 2015; 44:533-5. [PMID: 26678232 DOI: 10.3928/00904481-20151111-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Slovis TL, Strouse PJ, Strauss KJ. Radiation Exposure in Imaging of Suspected Child Abuse: Benefits versus Risks. J Pediatr 2015; 167:963-8. [PMID: 26354874 DOI: 10.1016/j.jpeds.2015.07.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/29/2015] [Accepted: 07/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas L Slovis
- Department of Radiology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI
| | - Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Department of Radiology, University of Michigan Health System, Ann Arbor, MI.
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Abstract
BACKGROUND Abusive head trauma (AHT) is an important cause of serious brain injury in infants and young children who have characteristic clinical and imaging findings that are discordant with the clinical history provided. Recent attention has focused on abnormalities of the cranial venous sinuses and cortical veins, both on MRI and at autopsy. Although many have interpreted these to be secondary to the AHT, some have recently argued that these venous abnormalities represent primary cortical sinus and venous thrombosis that leads secondarily to subdural hemorrhage and secondary brain injury. Direct trauma to the veins and sinuses has been reported at autopsy in AHT, but there has been no systematic study of venous abnormalities in cases of AHT. OBJECTIVE The purpose of this study was to define the incidence and characteristics of venous and sinus abnormalities in AHT. MATERIALS AND METHODS We included all children <36 months of age who were diagnosed with abusive head trauma between 2001 and 2012 and who had MRI and magnetic resonance (MR) venography as part of their diagnostic workup. We analyzed age, gender and clinical findings. MRI and MR venography were analyzed independently by two neuroradiologists with a focus on abnormalities involving the intracranial veins and venous sinuses. RESULTS A total of 45 children were included. The median age was 3 months (range 15 days to 31 months) and 28 were boys (62%). Clinical findings included retinal hemorrhage in 71% and extracranial fractures in 55%. CT or MRI demonstrated subdural hemorrhage in 41 (91%); none had subdural effusions. In 31 cases (69%) MR venography demonstrated mass effect on the venous sinuses or cortical draining veins, with either displacement or partial or complete effacement of the venous structures from an adjacent subdural hematoma or brain swelling. We also describe the lollipop sign, which represents direct trauma to the cortical bridging veins and was present in 20/45 (44%) children. CONCLUSION Evidence of displacement or compression of cortical veins and sinuses from subdural hemorrhage or edema on MR venography was present in the majority of children with abusive head trauma. Evidence of direct trauma to the veins (lollipop sign) was identified in nearly half of cases. It is important to understand the superimposed effects of subdural hematoma and brain swelling on the veins and sinuses to differentiate it from cortical sinus and venous thrombosis.
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Affiliation(s)
- Arabinda K Choudhary
- Department of Radiology, Nemours A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, USA.
| | - Ray Bradford
- Department of Radiology, Hershey Medical Center, Hershey, PA, USA
| | - Mark S Dias
- Department of Neurosurgery, Hershey Medical Center, Hershey, PA, USA
| | - K Thamburaj
- Department of Radiology, Hershey Medical Center, Hershey, PA, USA
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Abstract
OBJECT In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury. METHODS Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion. RESULTS In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141-2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates. CONCLUSIONS The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.
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Affiliation(s)
- Joseph H Piatt
- Nemours Neuroscience Center, AI duPont Hospital for Children, Wilmington, Delaware; and Departments of Neurological Surgery and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Palasis S, Hayes LL. Acquired pathology of the pediatric spine and spinal cord. Pediatr Radiol 2015; 45 Suppl 3:S420-32. [PMID: 26346148 DOI: 10.1007/s00247-015-3328-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/21/2014] [Accepted: 02/24/2015] [Indexed: 12/13/2022]
Abstract
Pediatric spine pathology poses a diagnostic challenge for radiologists. Acquired spine pathology often yields nonspecific signs and symptoms in children, especially in the younger age groups, and diagnostic delay can carry significant morbidity. This review is focused on some of the more common diagnostic dilemmas we face when attempting to evaluate and diagnose acquired pediatric spine anomalies in daily practice. An understanding of some of the key differentiating features of these disease processes in conjunction with pertinent history, physical exam, and advanced imaging techniques can indicate the correct diagnosis.
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Affiliation(s)
- Susan Palasis
- Department of Radiology at Scottish Rite, Children's Healthcare of Atlanta, 1001 Johnson Ferry Road, Atlanta, GA, 30342, USA,
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