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Use of whole body MRI in detecting body injuries in suspected child abuse: A case report
Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
Use of whole body MRI in detecting body injuries in suspected child abuse: A case report Michelle T. Ruda a,n, Christopher S. Greeley b, Jennifer H. Johnston c, Susan D. John d a
The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1425, Houston, TX 77030, USA The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.106, Houston, TX 77030, USA c The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX 77030, USA d The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.100, Houston, TX 77030, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 9 April 2015 Received in revised form 30 May 2015 Accepted 23 August 2015
Skeletal surveys are currently considered standard-of-care for the evaluation of fractures in infants with suspected abuse. It has been well described that subtle fractures may be missed and soft tissue and visceral injuries are often undetected using this radiographic modality [3]. Whole body MRI (WB-MRI) is mainly used in oncology and infectious disease, however, its application in the field of child abuse pediatrics has not been well studied. We present a case that illustrates the potential utility of WB-MRI using a 3 T magnet in evaluating infants with suspected child abuse. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Non-accidental trauma Abusive head trauma Skeletal survey Fracture Rib fracture Visceral injury Soft-tissue injury Shaken baby syndrome
1. Introduction The value of MRI in the evaluation of suspected abusive head trauma (AHT) was initially demonstrated in 1989. It has primarily been used to assess for intracranial injury. In pediatric patients, whole-body MRI (WB-MRI) is most commonly used in oncology to assess for metastatic disease or for multifocal osteomyelitis. Initially described in 2006 [4], WB-MRI has had limited evaluation as a diagnostic modality in suspected AHT. In 2007, Stranzinger and colleagues reported on a 2-month-old infant with suspected AHT in whom rib fractures were identified on WB-MRI STIR imaging that were “only partially recognized by conventional radiography” [5]. Also in 2007, Eltermann and colleagues reported their experience in using WB-MRI in 4 cases of suspected physical child abuse [6]. A retrospective report in 2010 reviewed an institutional experience of 20 infants with suspected AHT who received WBMRI using a 1.5 T magnet in addition to the routine skeletal survey n
Corresponding author. Fax: þ 1 713 500 0721 E-mail addresses: [email protected] (M.T. Ruda), [email protected] (C.S. Greeley), [email protected] (J.H. Johnston), [email protected] (S.D. John).
[7]. These authors concluded WB-MRI using a 1.5 T magnet was too insensitive in evaluating for particular subtle fractures (e.g. rib and metaphyseal fractures) as compared to skeletal surveys; however, the authors reported identified soft tissue injuries that led to finding additional fractures not seen on the initial skeletal survey. As part of a prospective AHT research protocol, we hypothesize that with current advances in imaging technology and software and the use of a 3 T magnet, WB-MRI will be comparable to the standard skeletal survey in identifying skeletal injuries in infant victims of non-accidental injury. Furthermore, we propose that WB-MRI will provide additional clinically meaningful information, particularly regarding intra-abdominal and intra-thoracic visceral injury, that would otherwise not be identified by routine clinical evaluation. We currently report one subject who as part of her clinical evaluation, received a 3 T WB-MRI study, which supports that WB-MRI may be a meaningful imaging strategy in infants with suspected child abuse. 1.1. Case report A two-month-old female infant presented to the emergency department for an apparent life-threatening event (ALTE) while at
http://dx.doi.org/10.1016/j.jofri.2015.08.003 2212-4780/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i
2
M.T. Ruda et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
home under her father’s supervision. The infant was born at 31 weeks of gestation with a past medical history significant for a hospitalization three weeks prior for a subdural hematoma from a reported fall while in father’s arms. A CT scan of the head demonstrated bilateral extra-axial blood surrounding the frontal lobes, left temporo-occipital parenchymal hemorrhage with surrounding subdural hematoma and suspected trauma to the left lambdoid suture. At that time, her physical examination was significant for bruising to the left cheek and shoulder where her father reportedly braced her fall. The child’s skeletal survey, ophthalmologic evaluation and coagulation studies were found to be normal. Being without further predisposing medical conditions, her intracranial injury was deemed non-specific for abuse by the hospital’s child protection team. The child was discharged home with her mother after being cleared by children’s protective services. A repeat skeletal survey obtained 14 days later was read as normal. Three weeks later, the father found the infant apneic at home. He administered chest compressions and rescue breaths and the infant quickly returned to baseline. Eight hours after this event she was reported to be fussier than usual and began vomiting, prompting the second emergency department evaluation. Her initial assessment was normal except for elevated transaminases (ALT¼ 265, AST ¼152). Subsequent evaluation included an abdominal ultrasound which raised concern for an adrenal mass (Fig. 1). Further imaging comprised of a complete skeletal survey reported as negative (Fig. 2) and a head CT with bilateral subdural hemorrhages. A WB-MRI examination was obtained in conjunction with a brain MRI. Coronal and sagittal STIR images were obtained from the neck to the heels on a 3 T magnet taking an estimated 100 min. The brain MRI demonstrated multiple areas of sub-acute infarction, contusion and hemorrhage as well as large chronic subdural hematomas. As part of a prospective research protocol, a pediatric radiologist who was blinded to the clinical and imaging data reviewed the initial WB-MRI. A second, unmasked reading was then performed and entered into the infant’s medical records. The blinded WB-MRI reading revealed an adrenal hematoma, multiple liver lacerations, bilateral rib fractures, and subcutaneous tissue edema of both arms and the flank (Figs 3 and 4). Retrospective review of the most recent skeletal survey detected a fracture of the right first rib (Fig. 2), which was not reported on the initial reading made by a pediatric radiologist. A skeletal survey repeated 14 days later confirmed several bilateral healing rib fractures (Fig. 5). These identified injuries provided additional evidence for physical abuse. The child was discharged home with her grandparents and had no further injuries at follow up.
Fig. 1. Right upper quadrant ultrasound shows a right suprarenal complex mass (arrows).
Fig. 2. Skeletal survey at the time of representation shows a fracture of the right first rib that was initially missed (arrow). No other rib fractures are well appreciated.
Fig. 3. Whole body MRI STIR image shows a linear hyperintense region near the gallbladder fossa consistent with a liver laceration (arrow). The heterogeneous right suprarenal hematoma is also seen (arrowhead).
2. Discussion The cornerstone of the diagnosis of AHT involves a comprehensive medical history and thorough physical examination, including a careful ophthalmologic examination. Imaging studies and targeted laboratory evaluations are often critical to explore a comprehensive differential diagnosis and assess for clinically unapparent injuries. The imaging of infants with suspected AHT typically includes a CT scan of the head and a radiographic skeletal survey. [1] Commonly, MRI of the brain and spinal cord are performed on infants found to have abnormal findings on initial CT scan, or persistent neurologic deficits on examination. Although radiographic quality has improved, the relatively low sensitivity of skeletal surveys in detecting subtle skeletal injuries (rib fractures in particular) is well described, making a follow-up skeletal survey strongly recommended [1–3]. Additionally, there is growing concern about the cumulative radiation exposure received from multiple imaging modalities utilized throughout a comprehensive evaluation for AHT. This case report demonstrates the potential value of WB-MRI in the evaluation of infants with suspected child abuse. In this case, WB-MRI using a 3 T magnet was able to identify skeletal, soft tissue and visceral injuries not fully appreciated on skeletal survey and ultrasound. The blinded nature of this report supports our hypothesis that with improved technology and increased accessibility, WB-MRI may be a reasonable adjunct in suspected child abuse evaluations. Given the growing body of literature on WBMRI in the evaluation of infants with suspected non-accidental injuries, a blinded, carefully planned, multi-site, prospective
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i
M.T. Ruda et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
Fig. 4. Whole body MRI. Coronal (a, b) STIR images shows increased signal around the right first rib and around several right upper ribs (arrows), corresponding to fractures noted on repeat skeletal survey. Liver lacerations (arrowhead) and right suprarenal hematoma (dash arrow) are also seen. Axial (c) STIR image demonstrates a step-off at the lateral aspect of a left upper rib, concerning for a fracture (arrow).
References
Fig. 5. Repeat skeletal survey obtained 14 days after the initial skeletal survey shows multiple healing right 1st, 3rd, 4th, 5th, 6th and left 4th rib fractures (arrows).
[1] N.D. Kellogg, American Academy of Pediatrics Committee on Child A, Neglect, Evaluation of suspected child physical abuse, Pediatrics 119 (6) (2007) 1232–1241. [2] E.G. Flaherty, J.M. Perez-Rossello, M.A. Levine, et al., Evaluating children with fractures for child physical abuse, Pediatrics 133 (2) (2014) e477–e489 , Feb. [3] A.M. Kemp, A. Butler, S. Morris, et al., Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin. Radiol. 61 (9) (2006) 723–736. [4] J.M. Perez-Rossello, S.A. Connolly, D. Zurakowski, P.K. Kleinman, Whole-body M. R.I. in the evaluation of suspected infant abuse. Radiological Society of North America 2006 Scientific Assembly and Annual Meeting, Chicago, IL, 2006. [5] E. Stranzinger, C.J. Kellenberger, S. Braunschweig, R. Hopper, T.A.G.M. Huisman, Whole-body STIR MR imaging in suspected child abuse: an alternative to skeletal survey radiography? Eur. J. Radiol. Extra 63 (1) (2007) 43–47. [6] T. Eltermann, M. Beer, H.J. Girschick, Magnetic resonance imaging in child abuse, J. Child Neurol. 22 (2) (2007) 170–175. [7] J.M. Perez-Rossello, S.A. Connolly, A.W. Newton, K.H. Zou, P.K. Kleinman, M.R. I. Whole-body, in suspected infant abuse, Am. J. Roentgenol. 195 (3) (2010) 744–750.
evaluation of the diagnostic potential for this promising modality is warranted.
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
Use of whole body MRI in detecting body injuries in suspected child abuse: A case report Michelle T. Ruda a,n, Christopher S. Greeley b, Jennifer H. Johnston c, Susan D. John d a
The University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 1425, Houston, TX 77030, USA The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.106, Houston, TX 77030, USA c The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX 77030, USA d The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 2.100, Houston, TX 77030, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 9 April 2015 Received in revised form 30 May 2015 Accepted 23 August 2015
Skeletal surveys are currently considered standard-of-care for the evaluation of fractures in infants with suspected abuse. It has been well described that subtle fractures may be missed and soft tissue and visceral injuries are often undetected using this radiographic modality [3]. Whole body MRI (WB-MRI) is mainly used in oncology and infectious disease, however, its application in the field of child abuse pediatrics has not been well studied. We present a case that illustrates the potential utility of WB-MRI using a 3 T magnet in evaluating infants with suspected child abuse. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Non-accidental trauma Abusive head trauma Skeletal survey Fracture Rib fracture Visceral injury Soft-tissue injury Shaken baby syndrome
1. Introduction The value of MRI in the evaluation of suspected abusive head trauma (AHT) was initially demonstrated in 1989. It has primarily been used to assess for intracranial injury. In pediatric patients, whole-body MRI (WB-MRI) is most commonly used in oncology to assess for metastatic disease or for multifocal osteomyelitis. Initially described in 2006 [4], WB-MRI has had limited evaluation as a diagnostic modality in suspected AHT. In 2007, Stranzinger and colleagues reported on a 2-month-old infant with suspected AHT in whom rib fractures were identified on WB-MRI STIR imaging that were “only partially recognized by conventional radiography” [5]. Also in 2007, Eltermann and colleagues reported their experience in using WB-MRI in 4 cases of suspected physical child abuse [6]. A retrospective report in 2010 reviewed an institutional experience of 20 infants with suspected AHT who received WBMRI using a 1.5 T magnet in addition to the routine skeletal survey n
Corresponding author. Fax: þ 1 713 500 0721 E-mail addresses: [email protected] (M.T. Ruda), [email protected] (C.S. Greeley), [email protected] (J.H. Johnston), [email protected] (S.D. John).
[7]. These authors concluded WB-MRI using a 1.5 T magnet was too insensitive in evaluating for particular subtle fractures (e.g. rib and metaphyseal fractures) as compared to skeletal surveys; however, the authors reported identified soft tissue injuries that led to finding additional fractures not seen on the initial skeletal survey. As part of a prospective AHT research protocol, we hypothesize that with current advances in imaging technology and software and the use of a 3 T magnet, WB-MRI will be comparable to the standard skeletal survey in identifying skeletal injuries in infant victims of non-accidental injury. Furthermore, we propose that WB-MRI will provide additional clinically meaningful information, particularly regarding intra-abdominal and intra-thoracic visceral injury, that would otherwise not be identified by routine clinical evaluation. We currently report one subject who as part of her clinical evaluation, received a 3 T WB-MRI study, which supports that WB-MRI may be a meaningful imaging strategy in infants with suspected child abuse. 1.1. Case report A two-month-old female infant presented to the emergency department for an apparent life-threatening event (ALTE) while at
http://dx.doi.org/10.1016/j.jofri.2015.08.003 2212-4780/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i
2
M.T. Ruda et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
home under her father’s supervision. The infant was born at 31 weeks of gestation with a past medical history significant for a hospitalization three weeks prior for a subdural hematoma from a reported fall while in father’s arms. A CT scan of the head demonstrated bilateral extra-axial blood surrounding the frontal lobes, left temporo-occipital parenchymal hemorrhage with surrounding subdural hematoma and suspected trauma to the left lambdoid suture. At that time, her physical examination was significant for bruising to the left cheek and shoulder where her father reportedly braced her fall. The child’s skeletal survey, ophthalmologic evaluation and coagulation studies were found to be normal. Being without further predisposing medical conditions, her intracranial injury was deemed non-specific for abuse by the hospital’s child protection team. The child was discharged home with her mother after being cleared by children’s protective services. A repeat skeletal survey obtained 14 days later was read as normal. Three weeks later, the father found the infant apneic at home. He administered chest compressions and rescue breaths and the infant quickly returned to baseline. Eight hours after this event she was reported to be fussier than usual and began vomiting, prompting the second emergency department evaluation. Her initial assessment was normal except for elevated transaminases (ALT¼ 265, AST ¼152). Subsequent evaluation included an abdominal ultrasound which raised concern for an adrenal mass (Fig. 1). Further imaging comprised of a complete skeletal survey reported as negative (Fig. 2) and a head CT with bilateral subdural hemorrhages. A WB-MRI examination was obtained in conjunction with a brain MRI. Coronal and sagittal STIR images were obtained from the neck to the heels on a 3 T magnet taking an estimated 100 min. The brain MRI demonstrated multiple areas of sub-acute infarction, contusion and hemorrhage as well as large chronic subdural hematomas. As part of a prospective research protocol, a pediatric radiologist who was blinded to the clinical and imaging data reviewed the initial WB-MRI. A second, unmasked reading was then performed and entered into the infant’s medical records. The blinded WB-MRI reading revealed an adrenal hematoma, multiple liver lacerations, bilateral rib fractures, and subcutaneous tissue edema of both arms and the flank (Figs 3 and 4). Retrospective review of the most recent skeletal survey detected a fracture of the right first rib (Fig. 2), which was not reported on the initial reading made by a pediatric radiologist. A skeletal survey repeated 14 days later confirmed several bilateral healing rib fractures (Fig. 5). These identified injuries provided additional evidence for physical abuse. The child was discharged home with her grandparents and had no further injuries at follow up.
Fig. 1. Right upper quadrant ultrasound shows a right suprarenal complex mass (arrows).
Fig. 2. Skeletal survey at the time of representation shows a fracture of the right first rib that was initially missed (arrow). No other rib fractures are well appreciated.
Fig. 3. Whole body MRI STIR image shows a linear hyperintense region near the gallbladder fossa consistent with a liver laceration (arrow). The heterogeneous right suprarenal hematoma is also seen (arrowhead).
2. Discussion The cornerstone of the diagnosis of AHT involves a comprehensive medical history and thorough physical examination, including a careful ophthalmologic examination. Imaging studies and targeted laboratory evaluations are often critical to explore a comprehensive differential diagnosis and assess for clinically unapparent injuries. The imaging of infants with suspected AHT typically includes a CT scan of the head and a radiographic skeletal survey. [1] Commonly, MRI of the brain and spinal cord are performed on infants found to have abnormal findings on initial CT scan, or persistent neurologic deficits on examination. Although radiographic quality has improved, the relatively low sensitivity of skeletal surveys in detecting subtle skeletal injuries (rib fractures in particular) is well described, making a follow-up skeletal survey strongly recommended [1–3]. Additionally, there is growing concern about the cumulative radiation exposure received from multiple imaging modalities utilized throughout a comprehensive evaluation for AHT. This case report demonstrates the potential value of WB-MRI in the evaluation of infants with suspected child abuse. In this case, WB-MRI using a 3 T magnet was able to identify skeletal, soft tissue and visceral injuries not fully appreciated on skeletal survey and ultrasound. The blinded nature of this report supports our hypothesis that with improved technology and increased accessibility, WB-MRI may be a reasonable adjunct in suspected child abuse evaluations. Given the growing body of literature on WBMRI in the evaluation of infants with suspected non-accidental injuries, a blinded, carefully planned, multi-site, prospective
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i
M.T. Ruda et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
Fig. 4. Whole body MRI. Coronal (a, b) STIR images shows increased signal around the right first rib and around several right upper ribs (arrows), corresponding to fractures noted on repeat skeletal survey. Liver lacerations (arrowhead) and right suprarenal hematoma (dash arrow) are also seen. Axial (c) STIR image demonstrates a step-off at the lateral aspect of a left upper rib, concerning for a fracture (arrow).
References
Fig. 5. Repeat skeletal survey obtained 14 days after the initial skeletal survey shows multiple healing right 1st, 3rd, 4th, 5th, 6th and left 4th rib fractures (arrows).
[1] N.D. Kellogg, American Academy of Pediatrics Committee on Child A, Neglect, Evaluation of suspected child physical abuse, Pediatrics 119 (6) (2007) 1232–1241. [2] E.G. Flaherty, J.M. Perez-Rossello, M.A. Levine, et al., Evaluating children with fractures for child physical abuse, Pediatrics 133 (2) (2014) e477–e489 , Feb. [3] A.M. Kemp, A. Butler, S. Morris, et al., Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin. Radiol. 61 (9) (2006) 723–736. [4] J.M. Perez-Rossello, S.A. Connolly, D. Zurakowski, P.K. Kleinman, Whole-body M. R.I. in the evaluation of suspected infant abuse. Radiological Society of North America 2006 Scientific Assembly and Annual Meeting, Chicago, IL, 2006. [5] E. Stranzinger, C.J. Kellenberger, S. Braunschweig, R. Hopper, T.A.G.M. Huisman, Whole-body STIR MR imaging in suspected child abuse: an alternative to skeletal survey radiography? Eur. J. Radiol. Extra 63 (1) (2007) 43–47. [6] T. Eltermann, M. Beer, H.J. Girschick, Magnetic resonance imaging in child abuse, J. Child Neurol. 22 (2) (2007) 170–175. [7] J.M. Perez-Rossello, S.A. Connolly, A.W. Newton, K.H. Zou, P.K. Kleinman, M.R. I. Whole-body, in suspected infant abuse, Am. J. Roentgenol. 195 (3) (2010) 744–750.
evaluation of the diagnostic potential for this promising modality is warranted.
Please cite this article as: M.T. Ruda, et al., Use of whole body MRI in detecting body injuries in suspected child abuse: A case report, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.08.003i