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Abusive head trauma Part II: radiological aspects.

Sieswerda-Hoogendoorn T, Boos S, Spivack B, Bilo RA, van Rijn RR - Eur. J. Pediatr. (2011)

Bottom Line: There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive.If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

View Article: PubMed Central - PubMed

Affiliation: Section Forensic Paediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands. T.Sieswerda@amc.uva.nl

ABSTRACT

Unlabelled: Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.

Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

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a A two-year-old girl with a subdural haematoma along the left convexity (arrow) and diffuse ischaemia (asterisk) as a result of abusive head trauma. b Diffusion-weighted MRI, obtained on the same day as the MRI, shows extensive temporoparietal cytotoxic oedema as a result of disturbed perfusion (restricted diffusion). c Diffusion-weighted MRI (apparent diffusion coefficient) shows a corresponding decrease in signal intensity. d Blood clot in the subdural haematoma shown on the FLuid Attenuation Inversion Recovery (FLAIR) image. This sequence uses a long TI in order to suppress the effect of fluid on the images. It can be used to show lesions that are normally obscured by the high signal intensity of fluid. e Chest radiographs obtained 3 weeks after the incident shows a consolidating posterior ribfracture (see insert). This was not visible on the initial skeletal survey and this shows the importance of a repeat skeletal survey in case of inconclusive findings. f MRI obtained after 2 months of the incident shows extensive diffuse multicystic encephalomalacia and bilateral subdural hygromas (asterisk)
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Fig6: a A two-year-old girl with a subdural haematoma along the left convexity (arrow) and diffuse ischaemia (asterisk) as a result of abusive head trauma. b Diffusion-weighted MRI, obtained on the same day as the MRI, shows extensive temporoparietal cytotoxic oedema as a result of disturbed perfusion (restricted diffusion). c Diffusion-weighted MRI (apparent diffusion coefficient) shows a corresponding decrease in signal intensity. d Blood clot in the subdural haematoma shown on the FLuid Attenuation Inversion Recovery (FLAIR) image. This sequence uses a long TI in order to suppress the effect of fluid on the images. It can be used to show lesions that are normally obscured by the high signal intensity of fluid. e Chest radiographs obtained 3 weeks after the incident shows a consolidating posterior ribfracture (see insert). This was not visible on the initial skeletal survey and this shows the importance of a repeat skeletal survey in case of inconclusive findings. f MRI obtained after 2 months of the incident shows extensive diffuse multicystic encephalomalacia and bilateral subdural hygromas (asterisk)

Mentions: Kemp et al. performed a systematic review to determine the optimal imaging strategy to identify AHT [21]. As initial CT is widely accepted as modality of first choice in an acutely ill child with neurological symptoms, they included studies that compared additional MRI, follow-up CT and CUS with initial CT. Additional MRI revealed new information in at least 25% of all children with abnormalities on the initial CT scan. Additional findings detected by MRI were a.o. further SDH’s, sub-arachnoid haemorrhages, cranial shearing, ischaemia, infarction, parenchymal haemorrhages and cerebral contusions. DWI, a relatively new MRI technique described above, demonstrated more extensive injury than could be seen on normal MRI, correlated with poor outcome (Fig. 6a–f). The question whether children with no abnormalities on CT should undergo MRI cannot sufficiently be answered from the literature. The authors did find some studies that described children that had abnormalities on MRI in the presence of a normal CT, but study quality was too low to include these studies in the review. The role of repeat CT if early MRI was performed remains unclear from today’s literature. Studies on high resolution CUS described only 21 children who had CUS in total, but CUS failed to identify abnormalities in six cases. It can be concluded that there is evidence that the most solid way to identify intracranial injuries as a result of AHT is to perform initial CT. If CT is abnormal, early MRI including DWI should be performed. The role of MRI, if initial CT is normal, is unclear as is the role of repeat CT if early MRI is performed.Fig. 6


Abusive head trauma Part II: radiological aspects.

Sieswerda-Hoogendoorn T, Boos S, Spivack B, Bilo RA, van Rijn RR - Eur. J. Pediatr. (2011)

a A two-year-old girl with a subdural haematoma along the left convexity (arrow) and diffuse ischaemia (asterisk) as a result of abusive head trauma. b Diffusion-weighted MRI, obtained on the same day as the MRI, shows extensive temporoparietal cytotoxic oedema as a result of disturbed perfusion (restricted diffusion). c Diffusion-weighted MRI (apparent diffusion coefficient) shows a corresponding decrease in signal intensity. d Blood clot in the subdural haematoma shown on the FLuid Attenuation Inversion Recovery (FLAIR) image. This sequence uses a long TI in order to suppress the effect of fluid on the images. It can be used to show lesions that are normally obscured by the high signal intensity of fluid. e Chest radiographs obtained 3 weeks after the incident shows a consolidating posterior ribfracture (see insert). This was not visible on the initial skeletal survey and this shows the importance of a repeat skeletal survey in case of inconclusive findings. f MRI obtained after 2 months of the incident shows extensive diffuse multicystic encephalomalacia and bilateral subdural hygromas (asterisk)
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Related In: Results  -  Collection

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Fig6: a A two-year-old girl with a subdural haematoma along the left convexity (arrow) and diffuse ischaemia (asterisk) as a result of abusive head trauma. b Diffusion-weighted MRI, obtained on the same day as the MRI, shows extensive temporoparietal cytotoxic oedema as a result of disturbed perfusion (restricted diffusion). c Diffusion-weighted MRI (apparent diffusion coefficient) shows a corresponding decrease in signal intensity. d Blood clot in the subdural haematoma shown on the FLuid Attenuation Inversion Recovery (FLAIR) image. This sequence uses a long TI in order to suppress the effect of fluid on the images. It can be used to show lesions that are normally obscured by the high signal intensity of fluid. e Chest radiographs obtained 3 weeks after the incident shows a consolidating posterior ribfracture (see insert). This was not visible on the initial skeletal survey and this shows the importance of a repeat skeletal survey in case of inconclusive findings. f MRI obtained after 2 months of the incident shows extensive diffuse multicystic encephalomalacia and bilateral subdural hygromas (asterisk)
Mentions: Kemp et al. performed a systematic review to determine the optimal imaging strategy to identify AHT [21]. As initial CT is widely accepted as modality of first choice in an acutely ill child with neurological symptoms, they included studies that compared additional MRI, follow-up CT and CUS with initial CT. Additional MRI revealed new information in at least 25% of all children with abnormalities on the initial CT scan. Additional findings detected by MRI were a.o. further SDH’s, sub-arachnoid haemorrhages, cranial shearing, ischaemia, infarction, parenchymal haemorrhages and cerebral contusions. DWI, a relatively new MRI technique described above, demonstrated more extensive injury than could be seen on normal MRI, correlated with poor outcome (Fig. 6a–f). The question whether children with no abnormalities on CT should undergo MRI cannot sufficiently be answered from the literature. The authors did find some studies that described children that had abnormalities on MRI in the presence of a normal CT, but study quality was too low to include these studies in the review. The role of repeat CT if early MRI was performed remains unclear from today’s literature. Studies on high resolution CUS described only 21 children who had CUS in total, but CUS failed to identify abnormalities in six cases. It can be concluded that there is evidence that the most solid way to identify intracranial injuries as a result of AHT is to perform initial CT. If CT is abnormal, early MRI including DWI should be performed. The role of MRI, if initial CT is normal, is unclear as is the role of repeat CT if early MRI is performed.Fig. 6

Bottom Line: There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive.If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

View Article: PubMed Central - PubMed

Affiliation: Section Forensic Paediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands. T.Sieswerda@amc.uva.nl

ABSTRACT

Unlabelled: Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.

Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Show MeSH
Related in: MedlinePlus