Neuroimaging findings in abusive head trauma

Giulio Zuccoli, Ashok Panigrahy

and Rechel Berger1

Department of Radiology, Safar Resuscitation Center1, Child Abuse Advocacy, Children’s

Hospital of UPMC Pittsburgh,

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.

Older children with AHT at Children’s Hospital of

Pittsburgh

From 2005-2008, 36% of children were >1yr

0

5

10

15

20

25

30

35

40

2005 2006 2007 2008 2009

Number of cases >1 yr

Number of cases <1yr

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

Retinal hemorrhages Retinal

hemorrhage, unilateral or bilateral, often extending to the periphery and in multiple layers of the retina/retinoschisis

Subconjunctival hemorrhages

Neuroimaging Diagnose clinically unsuspected NAT

Determination of timing

Document the nature and extent of NAT

Diagnose conditions requiring immediate treatment

Rotational accelerationIs associated with: Diffuse axonal injury (DAI)

disruption of axons Tearing of bridging veins Subdural

hematoma Subarachnoid hemorrhage Retinal hemorrhage

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

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 acommon in NAT. It may be injury-related or hypoxia-related, being observed in suffocation, strangulation, post traumatic apnea.

3D reconstruction with a right parietal diastatic fracture.

Reversal sign

Han BK et al AJNR 1989;10:1191–1198.Kavanagh EC. Radiology. 2007;245:914-5.

Hypoxia/anoxia (drawoning, status epilepticus, asphyxia)

Infection (encephalitis/meningitis)

Trauma

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.

Subdural 6 m old male (NAT)

SDH

SDH

3-weeks-old female day 9 after trauma

1 month FU

Conventional 2D GRE 3D SWI

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

DWI\ADC

Suh DY et al Neurosurgery 2002;49,309-320.

Specificity: overlap with post ischemic spectrum

Spine, when? Lumbar kyphosis, thoraco-lumbar

swelling, focal neurological signs

Spine: findings

Fractures (Hangman’s, compression, dislocation),

Cord lesions, SDH, EH

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