neuroimaging findings in abusive head trauma
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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 - PowerPoint PPT PresentationTRANSCRIPT
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