Hemorrhages In Abusive Head Trauma Research Articles

Spinal subdural hemorrhage in abusive head trauma: a pictorial review.

A growing body of evidence links abusive head trauma (AHT) to patterns of direct and indirect spinal injuries, such as spinal subdural hemorrhage (SDH). Identification of evidence of spinal injury such as spinal SDH plays a crucial role in the diagnosis and subsequent management of the index child with AHT and his or her siblings. In a value-based practice of medicine, it can be argued that adding spine imaging to identify spinal SDH in the workup of AHT adds value to both the short- and long-term management of the patient. This pictorial review describes the normal appearance of spinal SDH and challenges of identifying spinal SDH, and it explores the mechanism of spinal SDH development in AHT.

Neuroradiologic timing of intracranial hemorrhage in abusive head trauma

Determining the timing of intracranial injuries in general, and abusive head trauma (AHT) in particular, is important to the care of children with traumatic brain injury. Additionally, identifying the time of the injury provides important information as to who might have, and who did not, inflict the trauma. Understanding the appearance and evolution of intracranial findings on neuroimaging has been an important factor in assessing the time of the injury. However, a number of studies in the last two decades have both suggested greater uncertainty about the reliability of this process and advanced our knowledge in this area. In this review, the authors consider the biophysical factors that contribute to the appearance and evolution of intracranial hemorrhage and, in particular, subdural hemorrhage (SDH). The traditional view of SDH is predicated largely on prior studies of intracerebral hemorrhage, although a number of variables make this comparison untenable. Moreover, more recent studies have suggested a number of factors that could alter the density (CT) or signal intensity (MRI) and produce mixed density/intensity SDH. These factors need to be considered in interpreting neuroimaging studies. A number of these recent studies evaluating serial neuroimaging in children with AHT have modified our understanding of intracranial hemorrhage and its evolution in this context. Taken together, the studies to date, having important limitations, provide only broad ranges over which to time injuries. The authors conclude that neuroimaging studies at this time are not likely, in isolation, to be able to accurately pinpoint a specific time of injury; rather, neuroimaging can only provide a range of possible times and should instead be used as a means to supplement or corroborate timing based on clinical presentation and other imaging findings.

Neuroimaging of retinal hemorrhage utilizing adjunct orbital susceptibility-weighted imaging

Retinal hemorrhages are an integral part of the evaluation of abusive head trauma (AHT). Timely detection of retinal hemorrhage not only facilitates the diagnosis of AHT, but has the potential to prevent further abuse to the child and the siblings and to identify the abuser. The gold standard for diagnosing retinal hemorrhage is a dilated fundoscopy exam, which requires pharmacological dilation. As such, there is a small percentage of patients for whom the dilated fundoscopy exam might be delayed. Evolving literature suggests that MRI, specifically susceptibility-weighted imaging (SWI), of the orbits might provide an alternative diagnostic tool for noninvasively detecting retinal hemorrhages, particularly when there is a delay in administering the dilated fundoscopy exam. In this paper we review the utility of SWI for detecting retinal hemorrhages in abusive head trauma, including discussion of diagnostic limitations and future research.

Novel in vivo depiction of optic nerves hemorrhages in child abuse: a 3D-SWI pilot study

PurposeUntil now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI.MethodsThirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected.ResultsThe average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages.ConclusionThis research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims.

Susceptibility-weighted imaging of retinal hemorrhages in abusive head trauma.

Retinal hemorrhages are one of the most important supportive evidences for abusive head trauma (AHT). Susceptibility-weighted imaging (SWI) is highly suited to identify various forms of intracranial hemorrhage in AHT. However its utility in imaging retinal hemorrhage is not well established. SWI is a sensitive sequence for identifying retinal hemorrhage on MRI. In this retrospective analysis, 26 consecutive infants and young children with a suspected admission diagnosis of AHT underwent indirect ophthalmoscopy and brain MRI protocol for AHT along with SWI. Brain susceptibility-weighted images of 14 age-matched children were used as controls. For detecting retinal hemorrhage, susceptibility-weighted images of patients and controls were reviewed randomly and independently by two neuroradiologists who were blinded to the history and ophthalmology findings. A pediatric ophthalmologist graded the indirect ophthalmoscopy images. A diagnosis of AHT was confirmed in all 26 cases from a multidisciplinary meeting. Indirect ophthalmoscopy images were available in 21 cases. Ophthalmoscopy was positive for retinal hemorrhage in the right eye in 18 cases (85.7%) and in the left eye in 16 cases (76.2%). On SWI, retinal hemorrhage was identified in the right eye in 9/21 cases (42.8%) and in the left eye in 8/21 cases (38.1%) of AHT. Analysis of SWI in 21 cases of AHT demonstrated a sensitivity of 50%, specificity of 100%, positive predictive value of 100% and negative predictive value of 32% for detecting retinal hemorrhage. SWI is moderately sensitive and highly specific for identifying retinal hemorrhage in AHT. Further studies are needed to identify steps to improve the efficiency of SWI in detecting retinal hemorrhage.

Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery

Retinal hemorrhage (RH) is one of the hallmarks of abusive head trauma (AHT); however, RH is also encountered with normal vaginal deliveries (NVD) and thus presents the clinician with a diagnostic dilemma. The purpose of this study was to compare RHs in AHT with those of NVD. Records of with AHT and NVD infants with RH evaluated from 2013 to 2015 were reviewed retrospectively. Pattern, size, extent, and severity were compared using RetCam images. Severities were calculated using the RH grading scale. A total of 20 patients with AHT and 200 NVD infants were included. RH size was significantly larger in AHT patients compared to the NVD group (3.1±0.512 vs 0.96±0.046 disk diameters, resp.). The AHT group also demonstrated a higher RH incidence involving all three retinal layers compared to the NVD group (60% vs 0.6%, resp. [P<0.001]). Vitreous hemorrhages were more common in the AHT group compared to the NVD group (54.3% vs 1.5% [P<0.001]). Also, the grading scale demonstrated higher scores in the AHT group than the NVD group (7.15±0.948 vs 3.59±0.274, resp.). AHT and NVD share similar retinal findings, but they also have unique differentiators. In our subjects, AHT presented with more severe retinal findings than NVD, including larger RH size, a higher percentage involving all three retinal layers, a higher percentage of vitreous hemorrhages, and higher RH grading scale scores. Also, NVD retinal hemorrhages resolved quickly, within 4weeks of birth in 95% of the patients.

Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery

Comparison of the characteristics of retinal hemorrhages in abusive head trauma versus normal vaginal delivery

Grading system for retinal hemorrhages in abusive head trauma: Clinical description and reliability study

There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes. A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients <3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC). There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P < 0.0001] and 100% agreement [Spearman r = 1.0; P < 0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P < 0.0001) confirmed a very high level of agreement overall. The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.

Erratum to: Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma

Author error during the proof stage resulted in an incorrect statement. Please note: In the results section the sentence, Compared with DFE, the MRI standard showed a sensitivity of 75% which increased to 83% for the orbits SWI protocol should be changed to: Compared with DFE, the MRI standard showed a sensitivity of 62% which increased to 80% for the orbits SWI protocol. The remaining data, including the table, appears to be correct.

Reliability of grading retinal hemorrhages in abusive head trauma

To study the intra- and inter-observer reliability of pediatric ophthalmologists in grading retinal hemorrhages in abusive head trauma. Pediatric ophthalmologists attending the 2009 annual meeting of the American Association for Pediatric Ophthalmology and Strabismus participated in an onsite survey. The participants were required to compare a collection of fundus photographs of patients with abusive head trauma to two standardized photographs, A and B. Participants graded photographs as normal (no retinal hemorrhages), better than A but not normal, same as A, between A and B, same as B, or worse than B. The survey was divided into four parts: part 1 consisted of 20 photographs to be graded; part 2 was a questionnaire about participant's professional experience; part 3 consisted of 20 photographs to be graded (including 15 graded in part 1 but reordered); and part 4 asked about the criteria used to grade the photographs. Of the 95 participants, 92 (97%) were licensed physicians with a mean of 14 years in practice. The intra-rater reliability was found to be high, with overall average of 85% pre- and post-agreement on the common pictures. Kendall's coefficient of concordance was used as the statistical measure of inter-rater reliability and had a high value (0.82). Pediatric ophthalmologists showed high intra- and inter-observer reliability in grading retinal hemorrhages in abusive head trauma.

Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma

IntroductionThis study aims to evaluate the capability of magnetic resonance imaging (MRI) susceptibility weighted images (SWI) in depicting retinal hemorrhages (RH) in abusive head trauma (AHT) compared to the gold standard dilated fundus exam (DFE).MethodsThis is a retrospective, single institution, observational study on 28 patients with suspected AHT, who had a DFE and also underwent brain MRI-SWI as part of routine diagnostic protocol. Main outcome measures involved evaluation of patients to determine whether the RH could be identified on standard and high-resolution SWI sequences.ResultsOf the 21 subjects with RH on DFE, 13 (62 %) were identified by using a standard SWI sequence performed as part of brain MRI protocols. Of the 15 patients who also underwent an orbits SWI protocol, 12 (80 %) were positive for RH. None of the seven patients without RH on of DFE had RH on either standard or high-resolution SWI. Compared with DFE, the MRI standard protocol showed a sensitivity of 75 % which increased to 83 % for the orbits SWI protocol.ConclusionsOur study suggests the usefulness of a tailored high-resolution orbits protocol to detect RH in AHT.

Incidence of Retinal Hemorrhages in Abusive Head Trauma

To evaluate whether a relationship exists between the presence of retinal hemorrhages and confessions and/or identified perpetrators in cases of abusive head trauma. A retrospective chart review was conducted of all abusive head trauma cases. All cases that met criteria for abusive head trauma were placed into one of three categories: perpetrator confessed (category A), perpetrator identified without confession (category B), and no perpetrator identified (category C). Forty-eight cases met the criteria for abusive head trauma, with 18, 16, and 14 cases in categories A, B, and C, respectively. Retinal hemorrhages were identified in 16 of 18 (88%) cases in category A, 12 of 16 (75%) in category B, and 6 of 14 (43%) in category C. A statistically significant difference regarding the presence of retinal hemorrhages was seen for perpetrator identified (28 of 34 or 82%) compared to no perpetrator identified (6 of 14 or 43%) (P = .034). The difference in retinal hemorrhages was correlated to the higher incidence of acute presentation in the perpetrator identified group (31 of 34 or 91%) compared to that in the perpetrator not identified group (9 of 14 or 64%) (P = .023). The incidence of retinal hemorrhages in abusive head trauma for identified perpetrators, regardless of a confession, is similar. However, there is a statistically significant decrease in the incidence of retinal hemorrhages in abusive head trauma when comparing identified perpetrators to non-identified perpetrators. This decreased incidence of retinal hemorrhages was statistically correlated to a lower incidence of acute presentation in victims of abusive head trauma without an identified perpetrator.[J Pediatr Ophthalmol Strabismus 2013;50(3):169-172.].

Spinal Subdural Hemorrhage in Abusive Head Trauma: A Retrospective Study

To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children. This study received prior approval from the Human Subjects Protection Office. Informed consent was waived. This study was HIPAA compliant. Two hundred fifty-two children aged 0-2 years treated for abusive head trauma at our institute between 1997 and 2009 were identified through retrospective chart review. A second group of 70 children aged 0-2 years treated at our institute for well-documented accidental trauma between 2003 and 2010 were also identified through retrospective chart review. All clinical data and cross-sectional imaging results, including computed tomographic and magnetic resonance imaging of the brain, spine, chest, abdomen, and pelvis, were reviewed for both of these groups. A Fisher exact test was performed to assess the statistical significance of the proportion of the spinal canal subdural hemorrhage in abusive head trauma versus that in accidental trauma. In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours ± 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001). Spinal canal subdural hemorrhage was present in more than 60% of children with abusive head trauma who underwent thoracolumbar imaging in this series but was rare in those with accidental trauma.

Levin AV. Retinal Hemorrhage in Abusive Head Trauma. Pediatrics. 2010;126(5):961-970

Errata| February 01 2011 Levin AV. Retinal Hemorrhage in Abusive Head Trauma. Pediatrics. 2010;126(5): 961–970 Pediatrics (2011) 127 (2): 398. https://doi.org/10.1542/peds.2010-3370 Connected Content This is a correction to: Retinal Hemorrhage in Abusive Head Trauma Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Levin AV. Retinal Hemorrhage in Abusive Head Trauma. Pediatrics. 2010;126(5): 961–970. Pediatrics February 2011; 127 (2): 398. 10.1542/peds.2010-3370 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP Grand RoundsAAP NewsAll AAP Sites Search Advanced Search Topics: craniocerebral trauma, retinal hemorrhage An error occurred in this article by Levin (doi: 10.1542/peds.2010-1220). The author did not identify any conflict of interest; however, in accordance with the policies of Pediatrics, Dr Levin declares that he has received compensation as an expert witness for both the prosecution and the defense in cases related to child abuse and shaken-baby syndrome. View Original Article You do not currently have access to this content.

Incidence of retinal hemorrhages in abusive head trauma: Comparison of cases of perpetrator confession, identifiable perpetrator without confession and no identifiable perpetrator

Purpose: Retinal hemorrhages (RH) are a cardinal feature of abusive head trauma (AHT) where characteristic hemorrhages in the setting of acute brain injury should be considered nonaccidental trauma until proven otherwise. We compared retinal hemorrhages of those cases where a perpetrator confessed to the act to those where a perpetrator was identified through other means. We also analyzed cases where a single perpetrator could not be identified.

Retinal Hemorrhage in Abusive Head Trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.

Pathology of retinal hemorrhage in abusive head trauma

Abusive head injury, characterized by repeated acceleration-deceleration forces, is associated with retinal hemorrhages as demonstrated in many clinical and postmortem studies. The theory that vitreoretinal traction is the major factor in the pathogenesis of retinal hemorrhages is presently the most widely accepted explanation based on different lines of research. Postmortem examination of the eye and orbital structures is essential for recognizing abusive head injury and also for identifying other possible medical conditions which can cause retinal hemorrhage.