- Email: [email protected]
Neuroimaging in child abuse: reducing the risk
Clinical Radiology (2004) 59, 965–966
EDITORIAL
Neuroimaging in child abuse: reducing the risk The most recent edition of “Making the Best Use of a Department of Clinical Radiology”1 states that a head CT examination is mandatory as part of a skeletal survey in children under 2 years of age being investigated for suspected child abuse. Although guidelines are just that, and clinicians have to make decisions about each case on its own merits, I suspect that there will be some disquiet expressed by both radiologists and paediatricians with regards to this recommendation. Similar recommendations have appeared in the paediatric literature2 and guidelines for neuroimaging when a diagnosis of abuse has been made have also recently been published.3 Child abuse is always an emotive topic. Children at risk of being, or who have been abused, need to be recognized promptly and protected appropriately. But this is tiger country: to get it wrong either way is potentially a tragedy; if abuse is not recognized a child may go back into an abusive environment risking further injury or worse; conversely an unfounded allegation can tear a family apart. The best way of trying to ensure that we don’t get it wrong is surely to have as much relevant information as possible upon which to base a decision in these cases. The true incidence of physical child abuse is not known but has probably not changed for centuries.4 The morbidity and mortality of physical abuse, however, has probably reduced because of appropriate intervention when abuse is recognized. Radiology has had an important part to play in this because ever since the association between metaphyseal and rib fractures and physical abuse was recognized, radiographic skeletal surveys have been used to look for these occult injuries. Radiologists may also be the first clinicians to raise the possibility of abuse when they see an injury on a radiograph that is unlikely to have occurred by the mechanism suggested on the request card. Although the identification of these clinically occult skeletal injuries is important from a forensic viewpoint, the vast majority of the mortality and morbidity associated with physical child abuse is due to head injury. Just as certain skeletal injuries can be occult so can intra-cranial injuries5 and it is likely that in most cases, subdural haematomas in non-accidental head injury (NAHI) are markers of a mechanism of injury rather than the primary cause
of symptoms. The symptoms with which these children present to hospital are variable and nonspecific. Similarly the outcome of these head injuries varies: some of these children die after NAHI, others will go on to develop cerebral palsy and still more probably suffer from varying degrees of poor neurodevelopmental outcomes.6 – 8 Outcomes after NAHI are worse than after accidental head injury in children injured to a similar degree.9,10 The mechanism of head injury in these cases is a matter of some debate as to whether shaking alone can lead to severe injuries or whether some kind of impact is always required. The details of the mechanism of injury are to some extent irrelevant in that the neuroimaging in these children often shows a combination of features that are rarely seen after all but the most severe accidental trauma: subdural haematomas in several sites (especially if the blood is in the inter-hemispheric fissure or posterior fossa) is a very unusual pattern after accidental head injury but very common after NAHI.11 – 13 There are often associated parenchymal changes with reduced grey –white differentiation and/or cerebral swelling, and sometimes more focal lesions such as haematomas and contusions. The signs and symptoms that infants and children present with after NAHI are variable. They range from being non-specifically unwell, off feeds or vomiting, reduced levels of consciousness or presenting with a frank encephalopathic illness and coma. Most of the subdural haematomas that are seen in cases of NAHI are shallow, low volume bleeds that do not show significant mass effect.14,15 It therefore seems unlikely that these bleeds are responsible for the presenting symptoms. What then is responsible? Evidence from radiology and pathology suggests that it is likely to be due to the degree of associated hypoxic-ischaemic injury to the brain. Diffusion weighted imaging (DWI) has been used in NAHI and the pattern seen is that of hypoxia rather than traumatic diffuse axonal injury,16,17 apnoea at or before presentation to hospital correlates with the extent of hypoxic changes on imaging and outcome,18 and neuropathology in fatal cases of NAHI shows hypoxic injury commonly and diffuse axonal (shearing) injury rarely.19,20 Just as metaphyseal and rib fractures are occult markers for a mechanism of injury, so are the
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.05.006
966
typical shallow subdurals seen in NAHI. We know that these can be clinically silent5 and it seems therefore illogical not to look for them in the same way that we look for skeletal injuries. Whilst it is true that a child who has no neurological signs and symptoms at the time of a skeletal survey will not have sustained a recent severe head injury, there may still be intra-cranial evidence of a NAHI, but we will not find that evidence unless we look! Recognizing the asymptomatic marker subdural haematomas this time could just prevent the more severe head injury next time. In this way a head CT examination as part of the skeletal survey is only a logical extension of what we already do in an attempt to detect the occult skeletal markers of abuse. For the child’s sake SCAN!
N. Stoodley
9. 10.
11. 12.
13.
14.
15. 16.
References 17. 1. RCR Working Party, Making the best use of a department of clinical radiology: guidelines for doctors, 5th ed. London: The Royal College of Radiologists; 2003. 2. Kemp AM. Investigating subdural haemorrhage in infants. Arch Dis Child 2002;86:98—102. 3. Jaspan T, Griffiths PD, McConachie NM, Punt JAG. Neuroimaging for non-accidental head injury in childhood: a proposed protocol. Clin Radiol 2003;58:44—53. 4. Knight B. The history of child abuse. Forensic Sci Int 1986;30: 135—41. 5. Greenes DS, Schutzman SA. Occult intra-cranial injury in infants. Ann Emerg Med 1998;32:680—6. 6. Bonnier C, Nassogne M, Evrard P. Outcome and prognosis of whiplash shaken infant syndrome: late consequences after a symptom free interval. Dev Med Child Neurol 1995;37: 943—56. 7. Duhaime AC, Christian CW, Moss E, Seidl TS. Long term outcome in infants with the shaking impact syndrome. Pediatr Neurosurg 1996;24:292—8. 8. Gilles EE, Nelson MD. Cerebral complications of non
18.
19.
20.
accidental head injury in childhood. Pediatr Neurol 1998; 19:119—28. Haviland J, Ross Russell J. Outcome after severe non accidental head injury. Arch Dis Child 1997;77:504—7. Prasad M, Ewing-Cobbs L, Swank PR, Kramer L. Predictors of outcome following traumatic brain injury in young children. Pediatr Neurosurg 2002;36:64—74. Billmire ME, Myers PA. Serious head injury in infants: accident or abuse? Pediatrics 1985;75:340—2. Dashti SR, Decker D, Razzaq A, Cohen AR. Current patterns of inflicted head injury in children. Pediatr Neurosurg 1999; 31:302—6. Ewing-Cobbs L, Prasad M, Kramer L, et al. Acute neuroradiologic findings in young children with inflicted or non inflicted traumatic brain injury. Child’s Nervous Syst 2000; 16:25—34. Duhaime AC, Christian CW, Armonda R, Hunter J, Hertle R. Disappearing subdural hematomas in children. Pediatr Neurosurg 1996;25:116—22. Johnson DL, Boal D, Baule R. Role of apnea in non accidental head injury. Pediatr Neurosurg 1995;23:305—10. Biousse V, Suh DY, Newman NJ, Davis PC, Mapstone TB, Lambert SR. Diffusion weighted magnetic resonance imaging in shaken baby syndrome. Am J Ophthalmol 2002;133: 249—55. Suh DY, Davis PC, Hopkins KL, Fajman NN, Mapstone TB. Non accidental pediatric head injury: diffusion weighted imaging findings. Neurosurgery 2001;49:309—20. Kemp AM, Stoodley N, Cobley C, Coles L, Kemp KW. Apnoea and brain swelling in non-accidental injury. Arch Dis Child 2003;88:472—6. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. 1. Patterns of brain damage. Brain 2001;124:1290—8. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. II: Microscopic brain injury in infants. Brain 2001;124: 1299—306.
N. Stoodley Department of Neuroradiology, Frenchay Hospital, Bristol, UK E-mail address: [email protected]
EDITORIAL
Neuroimaging in child abuse: reducing the risk The most recent edition of “Making the Best Use of a Department of Clinical Radiology”1 states that a head CT examination is mandatory as part of a skeletal survey in children under 2 years of age being investigated for suspected child abuse. Although guidelines are just that, and clinicians have to make decisions about each case on its own merits, I suspect that there will be some disquiet expressed by both radiologists and paediatricians with regards to this recommendation. Similar recommendations have appeared in the paediatric literature2 and guidelines for neuroimaging when a diagnosis of abuse has been made have also recently been published.3 Child abuse is always an emotive topic. Children at risk of being, or who have been abused, need to be recognized promptly and protected appropriately. But this is tiger country: to get it wrong either way is potentially a tragedy; if abuse is not recognized a child may go back into an abusive environment risking further injury or worse; conversely an unfounded allegation can tear a family apart. The best way of trying to ensure that we don’t get it wrong is surely to have as much relevant information as possible upon which to base a decision in these cases. The true incidence of physical child abuse is not known but has probably not changed for centuries.4 The morbidity and mortality of physical abuse, however, has probably reduced because of appropriate intervention when abuse is recognized. Radiology has had an important part to play in this because ever since the association between metaphyseal and rib fractures and physical abuse was recognized, radiographic skeletal surveys have been used to look for these occult injuries. Radiologists may also be the first clinicians to raise the possibility of abuse when they see an injury on a radiograph that is unlikely to have occurred by the mechanism suggested on the request card. Although the identification of these clinically occult skeletal injuries is important from a forensic viewpoint, the vast majority of the mortality and morbidity associated with physical child abuse is due to head injury. Just as certain skeletal injuries can be occult so can intra-cranial injuries5 and it is likely that in most cases, subdural haematomas in non-accidental head injury (NAHI) are markers of a mechanism of injury rather than the primary cause
of symptoms. The symptoms with which these children present to hospital are variable and nonspecific. Similarly the outcome of these head injuries varies: some of these children die after NAHI, others will go on to develop cerebral palsy and still more probably suffer from varying degrees of poor neurodevelopmental outcomes.6 – 8 Outcomes after NAHI are worse than after accidental head injury in children injured to a similar degree.9,10 The mechanism of head injury in these cases is a matter of some debate as to whether shaking alone can lead to severe injuries or whether some kind of impact is always required. The details of the mechanism of injury are to some extent irrelevant in that the neuroimaging in these children often shows a combination of features that are rarely seen after all but the most severe accidental trauma: subdural haematomas in several sites (especially if the blood is in the inter-hemispheric fissure or posterior fossa) is a very unusual pattern after accidental head injury but very common after NAHI.11 – 13 There are often associated parenchymal changes with reduced grey –white differentiation and/or cerebral swelling, and sometimes more focal lesions such as haematomas and contusions. The signs and symptoms that infants and children present with after NAHI are variable. They range from being non-specifically unwell, off feeds or vomiting, reduced levels of consciousness or presenting with a frank encephalopathic illness and coma. Most of the subdural haematomas that are seen in cases of NAHI are shallow, low volume bleeds that do not show significant mass effect.14,15 It therefore seems unlikely that these bleeds are responsible for the presenting symptoms. What then is responsible? Evidence from radiology and pathology suggests that it is likely to be due to the degree of associated hypoxic-ischaemic injury to the brain. Diffusion weighted imaging (DWI) has been used in NAHI and the pattern seen is that of hypoxia rather than traumatic diffuse axonal injury,16,17 apnoea at or before presentation to hospital correlates with the extent of hypoxic changes on imaging and outcome,18 and neuropathology in fatal cases of NAHI shows hypoxic injury commonly and diffuse axonal (shearing) injury rarely.19,20 Just as metaphyseal and rib fractures are occult markers for a mechanism of injury, so are the
0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2004.05.006
966
typical shallow subdurals seen in NAHI. We know that these can be clinically silent5 and it seems therefore illogical not to look for them in the same way that we look for skeletal injuries. Whilst it is true that a child who has no neurological signs and symptoms at the time of a skeletal survey will not have sustained a recent severe head injury, there may still be intra-cranial evidence of a NAHI, but we will not find that evidence unless we look! Recognizing the asymptomatic marker subdural haematomas this time could just prevent the more severe head injury next time. In this way a head CT examination as part of the skeletal survey is only a logical extension of what we already do in an attempt to detect the occult skeletal markers of abuse. For the child’s sake SCAN!
N. Stoodley
9. 10.
11. 12.
13.
14.
15. 16.
References 17. 1. RCR Working Party, Making the best use of a department of clinical radiology: guidelines for doctors, 5th ed. London: The Royal College of Radiologists; 2003. 2. Kemp AM. Investigating subdural haemorrhage in infants. Arch Dis Child 2002;86:98—102. 3. Jaspan T, Griffiths PD, McConachie NM, Punt JAG. Neuroimaging for non-accidental head injury in childhood: a proposed protocol. Clin Radiol 2003;58:44—53. 4. Knight B. The history of child abuse. Forensic Sci Int 1986;30: 135—41. 5. Greenes DS, Schutzman SA. Occult intra-cranial injury in infants. Ann Emerg Med 1998;32:680—6. 6. Bonnier C, Nassogne M, Evrard P. Outcome and prognosis of whiplash shaken infant syndrome: late consequences after a symptom free interval. Dev Med Child Neurol 1995;37: 943—56. 7. Duhaime AC, Christian CW, Moss E, Seidl TS. Long term outcome in infants with the shaking impact syndrome. Pediatr Neurosurg 1996;24:292—8. 8. Gilles EE, Nelson MD. Cerebral complications of non
18.
19.
20.
accidental head injury in childhood. Pediatr Neurol 1998; 19:119—28. Haviland J, Ross Russell J. Outcome after severe non accidental head injury. Arch Dis Child 1997;77:504—7. Prasad M, Ewing-Cobbs L, Swank PR, Kramer L. Predictors of outcome following traumatic brain injury in young children. Pediatr Neurosurg 2002;36:64—74. Billmire ME, Myers PA. Serious head injury in infants: accident or abuse? Pediatrics 1985;75:340—2. Dashti SR, Decker D, Razzaq A, Cohen AR. Current patterns of inflicted head injury in children. Pediatr Neurosurg 1999; 31:302—6. Ewing-Cobbs L, Prasad M, Kramer L, et al. Acute neuroradiologic findings in young children with inflicted or non inflicted traumatic brain injury. Child’s Nervous Syst 2000; 16:25—34. Duhaime AC, Christian CW, Armonda R, Hunter J, Hertle R. Disappearing subdural hematomas in children. Pediatr Neurosurg 1996;25:116—22. Johnson DL, Boal D, Baule R. Role of apnea in non accidental head injury. Pediatr Neurosurg 1995;23:305—10. Biousse V, Suh DY, Newman NJ, Davis PC, Mapstone TB, Lambert SR. Diffusion weighted magnetic resonance imaging in shaken baby syndrome. Am J Ophthalmol 2002;133: 249—55. Suh DY, Davis PC, Hopkins KL, Fajman NN, Mapstone TB. Non accidental pediatric head injury: diffusion weighted imaging findings. Neurosurgery 2001;49:309—20. Kemp AM, Stoodley N, Cobley C, Coles L, Kemp KW. Apnoea and brain swelling in non-accidental injury. Arch Dis Child 2003;88:472—6. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. 1. Patterns of brain damage. Brain 2001;124:1290—8. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. II: Microscopic brain injury in infants. Brain 2001;124: 1299—306.
N. Stoodley Department of Neuroradiology, Frenchay Hospital, Bristol, UK E-mail address: [email protected]