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Neuroimaging findings in abusive head trauma

Neuroimaging findings in abusive head trauma. Giulio Zuccoli , Ashok Panigrahy and Rechel Berger 1 Department of Radiology, Safar Resuscitation Center 1 , Child Abuse Advocacy, Children’s Hospital of UPMC Pittsburgh, . NAT: What is it?. The most common cause of death from child abuse

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Neuroimaging findings in abusive head trauma

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  1. Neuroimaging findings in abusive head trauma GiulioZuccoli, Ashok Panigrahy and Rechel Berger1 Department of Radiology, Safar Resuscitation Center1, Child Abuse Advocacy, Children’s Hospital of UPMC Pittsburgh,

  2. NAT: What is it? The most common cause of death from child abuse Leading cause of death from TBI in children <1 yr old Children aged 0-3 years are most likely to experience abuse Mild NAT may be up to 150x more common (Theodore et al, Pediatrics) Conservatively, about 2,000 cases/yr in the U.S.

  3. Older children with AHT at Children’s Hospital of Pittsburgh From 2005-2008, 36% of children were >1yr

  4. Less than 1/3 of children have the traditional triad of brain injury, retinal hemorrhages and fractures

  5. Retinal hemorrhages Retinal hemorrhage, unilateral or bilateral, often extending to the periphery and in multiple layers of the retina/retinoschisis Subconjunctival hemorrhages

  6. Neuroimaging Diagnose clinically unsuspected NAT Determination of timing Document the nature and extent of NAT Diagnose conditions requiring immediate treatment

  7. Rotational acceleration Is associated with: Diffuse axonal injury (DAI) disruption of axons Tearing of bridging veins  Subdural hematoma Subarachnoid hemorrhage Retinal hemorrhage

  8. Impact loading injuries Focal strains at the site of impact Pressure waves in the brain Are associated with Scalp hematoma Skull fracture SDH/SAH Brain contusion

  9. Shear Injury (DAI): The brain deforms readily in response to shear stress. Brain mostly shears at the gray-white junction. Contusion:Cerebral contusion is a focal hemorrhage within the brain parenchyma resulting from direct contact forces. Cerebral Edema:Edema, focal or diffuse, is a common in NAT. It may be injury-related or hypoxia-related, being observed in suffocation, strangulation, post traumatic apnea.

  10. 3D reconstruction with a right parietal diastatic fracture.

  11. Reversal sign • Hypoxia/anoxia (drawoning, status epilepticus, asphyxia) • Infection (encephalitis/meningitis) • Trauma Han BK et al AJNR 1989;10:1191–1198. Kavanagh EC. Radiology. 2007;245:914-5.

  12. Extraaxial Hemorrhage Epidural hematoma is not a specific sign of NAT SDH 46% (NAT) vs 10% (AT) SAH 31% (NAT) vs 8% (AT) Reece RM, Sege R. Arch Pediatr Adolesc Med 2000; 154:11–15.

  13. SDH Subdural 6 m old male (NAT)

  14. SDH

  15. 3-weeks-old female day 9 after trauma

  16. 1 month FU

  17. 3D SWI Conventional 2D GRE

  18. DWI\ADC • DWI in combination with ADC mapping allows better delineation of the degree of white matter involvement than conventional MRI • Patients showing evidence of global abnormalities on DWI suffer from severe cognitive or motor deficits • DWI may show additional areas of injury vs conventional MRI sequences in 25% of patients Suh DY et al Neurosurgery 2002;49,309-320.

  19. Specificity: overlap with post ischemic spectrum

  20. Spine, when? Lumbar kyphosis, thoraco-lumbar swelling, focal neurological signs Spine: findings • Fractures (Hangman’s, compression, dislocation), • Cordlesions, SDH, EH

  21. Summary SDH/SAH - often thin - often bilateral frontoparietal or interhemispheric, often without a skull fx Cerebral edema Diffuse axonal injury (DAI) Spinal lesions, SDH, EH No single finding is diagnostic of NAT Findings are always in the context of the history

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