Ashley Crosby 7/31/19

RADY 403 Case Presentation - NAT

Focused patient history and workup

• 37-day-old male presents to OSH with lethargy x24h

and difficulty feeding

• Outside workup: CT head w/subdural hematoma, CMP w/elevated LFTs

• Received pentobarbital for seizure-like activity prior to arrival

• Birth hx: unremarkable, SVD at term

• Transferred to UNC ED as a red trauma

• Initial ED trauma exam: hemodynamically stable, moving all 4 extremities, no focal deficits, some intermittent episodes of somnolence

• Initial ED workup: C-spine CT and abdomen/pelvis CT negative for additional injuries

• Admitted to PICU• Head CT repeated for comparison (~2hr later)• Consults: Neurosurgery, Peds surgery, Ophthalmology • Beacon was contacted at OSH

List of imaging studies

• Head CT x 2

• CT Cervical spine• No fracture or listhesis

• CT Abdomen/Pelvis• No evidence of acute trauma to the abdomen or pelvis

• Skeletal survey x 2

• Brain MRI, MRA, MRV • L parietal subdural hematoma w/cerebral edema and diffuse anoxic injury.

Small intraventricular hemorrhage• Narrowing of the L transverse sinus and proximal superior sagittal sinus. No

venous sinus thrombosis

Head CT without contrast

Acute left sided and parafalcine subdural

hematoma

Supratentorial edema suggestive of diffuse

cerebral anoxia, sparing the cerebellum (see

triangle)Cerebellum

Skeletal survey

Images from patient skeletal survey: No fractures identified

Cervical and thoracic spine (includes posterior ribs)

Right humerus Right foot Right hand

Skull with EEG leads limiting evaluation of the

calvarium

Lateral cervical spine Lateral thoracolumbar spine

Images from patient skeletal survey: No fractures identified

Skeletal survey

Skeletal survey – positive findings

Mildly displaced corner metaphyseal/bucket-handle fracture of the distal left tibial metaphysis. Questionable nondisplaced

bucket-handle fractures of the right ankle and left knee.

Subdural hemorrhage/hematoma is a collection of blood accumulating in the subdural space

- Subdural space: potential space between the dura and arachnoid mater of the meninges around the brain

- Can be diagnosed by CT; MRI useful to characterize brain parenchyma

- Result of stretching and tearing of bridging cortical veins as they cross the subdural space to drain into an adjacent dural sinus. These veins rupture due to shearing forces when there is a sudden change in the velocity of the head

- Typically crescent-shaped and more extensive than extradural hematomas. Not limited by sutures; limited by dural reflections, such as the falx cerebri, tentorium, falx cerebelli

Chronic subdural hemorrhage

Case courtesy of Dr David Cuete,Radiopaedia.org, rID: 23293

Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 21542

• 75-85% are bilateral in infants

• Common sites include frontoparietal convexities and middle cranial fossa

• Isolated interhemispheric or parafalcine subdural hematomas are seen more frequently in children and are common in cases of NAT

• Appearance on CT: varies with age and organization of clot• Hyperacute (~1 hour): isodense with swirl appearance • Acute: hyperdense• Subacute (3-21 days): isodense• Chronic: hypodense or isodense

• Appearance on MRI: also varies with age; most sensitive sequence is FLAIR• Hyperintense to CSF

Imaging features of subdural hematomas

ACR Appropriateness Criteria

*RRL of skeletal survey =0.3- 3 mSv Pediatric effective dose estimation range

*Skeletal scintigraphy is the most sensitive in detecting fractures of rib, scapula, spine, diaphysis and pelvis. Test becomes positive a few hours after injury. Normally there is high uptake in the physes of bones which should not be confused with a fracture.

Nonaccidental trauma (NAT) workup - Skeletal survey Fractures and relative specificity for child abuse

• Highly specific fractures• Metaphyseal lesions (i.e., bucket handle fracture, corner

fracture)• Present in up to 39-50% of abused infants <18 months;

virtually pathognomonic of NAT

• Posterior rib• Rib fractures may have no overlying bruising. CPR may cause

anterior rib fractures, but not posterior rib fractures

• Scapula• Spinous process• Sternum• Outer third of clavicle

• Moderately specific fractures• Multiple fractures• Fractures of different ages• Epiphyseal separations• Vertebral body• Digit• Complex skull

Low specificity but common• Middle clavicle• Long bone diaphysis• Linear skull

• Parietal skull fracture is more suggestive of accidental trauma

• Subperiosteal new bone formation

NAT skeletal survey imaging protocol• High quality detailed radiographs are critical in the assessment of skeletal injuries suspected from abuse

• Skeletal survey has 26+ images

• 2- Thorax: AP and lateral

• 2- Humerus: AP

• 2- Forearm: AP

• 2- Hands: PA

• 1- Pelvis: AP

• 2- Femurs: AP

• 2- Tibia/fibula: AP

• 2- Feet: AP

• 2- Skull: AP and lateral

• 2- Cervical spine: AP and lateral

• 1- Lumbosacral spine: lateral

• All lesions identified on the survey should be imaged in two projections

• Oblique views of the ribs will increase fracture yield

• Repeat skeletal survey in 10-14 days will identify subperiosteal bone reaction at site of subtle fractures

NB: Babygram is NOT an acceptable substitute – overall

low quality !!

NAT workup - other considerations

• Ophthalmology

• DSS report

• Child abuse pediatrics (UNC - Beacon)

Patient treatment/ outcome

• PICU course complicated by status epilepticus requiring midazolam gtt, fosphenytoin, phenobarbital, levetiracetam and lacosamide

• Intubated for airway protection; treated for aspiration pneumonia secondary to self-extubation. 7 day course of Unasyn

• Ophthalmology evaluation: multiple retinal hemorrhages

• Recently transferred to general peds floor

• Developed pleura empyema vs suprahepatic abscess; VIR for US-guided drainage and central access for antibiotics

Test Yourself Questions

1. Which of the following fractures is considered “highly suspicious” for NAT?

a. Posterior rib fracture

b. Long bone fracture

c. Ankle fracture

2. You have ordered a skeletal survey for your pediatric patient. When should a repeat skeletal survey be performed?

a. Follow up as needed

b. 10-14 days

c. 4-6 weeks

Test Yourself Answers

1. Which of the following fractures is considered “highly suspicious” for NAT?

a. Posterior rib fracture

b. Long bone fracture

c. Ankle fracture

2. You have ordered a skeletal survey for your pediatric patient. When should a repeat skeletal survey be performed?

a. Follow up as needed

b. 10-14 days

c. 4-6 weeks

References

• American College of Radiology: ACR Appropriateness Criteria. Suspected Physical Abuse – Child. Revised 2016.

• Bell DJ, Gaillard F et al. Subdural hemorrhage. Radiopaedia.org. https://radiopaedia.org/articles/subdural-haemorrhage?lang=us#image_list_item_5653240

• Cleveland Clinic Children’s Hospital. Child abuse skeletal trauma. Cleveland Clinic Pediatric Radiology Curriculum 2012. https://www.cchs.net/onlinelearning/cometvs10/pedrad/default.htm