Radiographic Evaluation of Inflicted Childhood Neurotrauma

1. Radiographic Evaluation of Inflicted ChildhoodNeurotrauma Robert A. Zimmerman, M.D. The Children’s Hospital of Philadelphia

2. Prospective Scottish Studyof Child Abuse Incidence 24.6 / 100,000 children Median age 2.2 months M > F Lancet 2000; 356: 1571-1572

3. Child Abuse Outcomes Mortality Non-accidental Accidental 13% 2% Arch Pediatr Adolesc Med 2000; 154: 11-15

4. #Pts%Abuse Chop pediatric ICU 1376 1.24% (Admissions 1 year) Mortality 5.8% 35.3% % Costs for traumatic brain injury with abuse vs. nonabuse (CHOP) = 54%

5. Risk factors that increase incidence of Child Abuse • Younger than 1 year • Military families • Premature infants (less than 28 weeks) • Mother less than 18 years • Less than 12 years education • Late prenatal care • Low income • Male infant

6. Perpetrators of Child Abuse • Father • Boyfriend • Female Babysitter • Mother

7. History } Child Abuse Minor Trauma Imaging Major Trauma

8. Child Abuse Mechanics of Craniocerebral Trauma • Beaten • Shaken

9. 6 week-old femaleinfant

11. Inflicted Childhood Neurotrauma Subdural Hematomas 16%, 65%, 67%, 69% • Subdural Hematomas • Size = 2-15 ml • Usually do not cause death because of mass effect

12. NAT3 month-old male CT T2 T2 FLAIR T2 ASL DWI DWI

13. Gliding Contusions

14. Diffuse Brain Swelling in ChildAbuse Delay between abuse and time medical attention is sought

15. Inflicted Childhood Neurotrauma Swelling/edema/infarction CT, MRI 15.6%, 34.5%, 71%, 77.7% Diffusion 69%, 89% Death = ICP

16. Diffusion Weighted Imaging in Non-Accidental Head Injury: Acute Injury Patterns Diffuse Supratentorial Injury 13 Watershed Supratentorial 12 Infratentorial (2) Venous Occlusion 4 Diffuse Axonal Injury 2 Gliding Contusion 2

17. T2 Diffusion Diffuse Supratentorial Injury

18. Diffusion Weighted Imaging in Non-Accidental Head Injury: Acute Injury Patterns • CT is the initial imaging modality in child abuse, however, while adequate for acute and chronic subdurals and gross advanced brain swelling, CT misses early cytotoxic edema and fails to give much information regarding mechanisms of injury. • MRI without diffusion is useful for subdurals, old, subcute and new, and for brain injury. • MRI diffusion imaging is very sensitive to acute brain injury and gives information regarding likely mechanism of injury.

19. Strangulation, Suffocation & Asphyxia 2,178 cases in 1995 in infants 29 / 100,000 children Arch Pediatr Adolesc Med 1997; 151: 72-77

20. Strangulation

21. Starvation

22. Retinal Hemorrhage

23. FAT SAT T2 Cranio-Cervical Injury

24. Child Abuse Clinical misdiagnosis of child abuse as: • Accidental trauma • Gastroenteritis, viral 25% suffer further injury before correct diagnosis is made.

26. Questions • How sensitive are our diagnostic studies in recognizing non-accidental trauma? • What is frequency of various injuries in non-accidental trauma? • Can we differentiate non-accidental from accidental injuries? • Timing of onset and evolution of injuries on imaging studies – Are there reliable criteria?