Abusive head trauma - Wikipedia
Abusive head trauma (AHT), commonly known as shaken baby syndrome (SBS), is an injury to . The terms non-accidental head injury or inflicted traumatic brain injury have been suggested instead of "SBS". The connection of the triad to episodes of traumatic shaking is controversial with a systematic review finding. correlation between the presence of SDB and brain weight. CONCLUSIONS: In the abusive head trauma, subdural bleeding, nonaccidental head injury, infant . Huang et al. examined the relationship between the economy and NAT. .. Comparison of accidental and nonaccidental traumatic brain injuries in infants and.
A literature review of this hypothesis in the journal Pediatrics International concluded the following: The most frequent neurological impairments are learning disabilities, seizure disorders, speech disabilities, hydrocephaluscerebral palsyand visual disorders.
John Caffeya pediatric radiologist, in describing a set of symptoms found with little or no external evidence of head trauma, including retinal bleeds and intracranial bleeds with subdural or subarachnoid bleeding or both. In the Court's ruling, they upheld the clinical concept of SBS but dismissed one case and reduced another from murder to manslaughter.
All the circumstances, including the clinical picture, must be taken into account. Geddes and colleagues, as an alternative mechanism for the subdural and retinal bleeding found in suspected cases of SBS. Edmunds a new trial based on "competing credible medical opinions in determining whether there is a reasonable doubt as to Edmunds's guilt. Infants are more susceptible to DAI due to their large head to body ratio, weak neck musculature and thinner skull.
DAI typically affects subcortical white matter, the corpus callosum, the brainstem and internal capsule Figure 1E. Intraparenchymal hematomas can result from shearing-straining injuries due to rupture of small intraparenchymal blood vessels and typically occurs in the fronto-temporal white matter Figure 1 Radiographic findings commonly seen in non-accidental trauma NAT.
Abusive Head Trauma | Clinical Updates | Mayerson Center
Secondary injuries include diffuse cerebral swelling, herniation, infarction, infection as well as chronic entities such as hydrocephalus or cerebrospinal fluid leak.
Diffuse cerebral swelling is usually seen hours following trauma and may occur more frequently in children than adults due to impaired autoregulation of perfusion and possibly an increased inflammatory response. Pediatric patients also generally have lower mean arterial pressures which results in greater likelihood for hypoperfusion and subsequent infarction Figure 1F.
Subfalcine, uncal or transtentorial herniation may all occur if significant mass effect develops either from the primary injury or from secondary diffuse cerebral edema. Hydrocephalus can also be a secondary injury which occurs when CSF absorption is impaired either due to obstruction or impaired resorption.
Finally, skull fractures can lead to CSF leaks, particularly when the skull base is involved and predisposes the patient to pneumococcal meningitis After a literature review, Sieswerda-Hoogendoorn et al.
The signs of AHT are often not recognized in less severe cases, so that it cannot be properly diagnosed. Children with mild encephalopathy may present with poor feeding, irritability, excessive crying or sleepiness. Those with moderate encephalopathy may present with lethargy, hypotonia, periods of apnea and diminished reflexes, such as grasping or sucking, while those with severe encephalopathy may present with seizures, stupor, coma or poorly reactive pupils When evaluating the child with intracranial hemorrhage, it is important to maintain a wide differential diagnosis, including accidental trauma or NAT, birth trauma, coagulopathy, congenital vascular malformations, spontaneous SDH, and metabolic deficiencies such as glutaric aciduria type I.
The possibility of spontaneous subdural hemorrhage in infants can complicate the determination of abusive trauma.
Analysis of Missed Cases of Abusive Head Trauma
The etiology of spontaneous subdural hemorrhage is thought to be related to benign enlargement of the subdural space BESSwhich typically begins with a rapid increase in head circumference at months of age and results in head circumference above the 95th percentile at 3 years of age. A study of children with BESS diagnosed on imaging were evaluated and four 2.
In 3 of the 4 children, a thorough evaluation did not reveal any additional signs of trauma and the SDH was determined to have occurred spontaneously Glutaric aciduria type I is a rare autosomal recessive neurometabolic disorder caused by a deficiency in glutaryl-CoA dehydrogenase, which affects the degradation of lysine, hydroxylysine, and tryptophan. The subsequent accumulation of glutaric acids results in hypotonia, acute striatal necrosis, frontotemporal atrophy and neurological deterioration.
Infants may present with macrocephaly and bilateral SDH, which may be mistakenly diagnosed as non-accidental trauma Ocular manifestations Ocular manifestations of NAT include periorbital hematoma, eyelid laceration, subconjunctival hemorrhage, subluxed or dislocated lens, cataracts, glaucoma, anterior chamber angle regression, iridiodialysis, retinal dialysis or detachment, intraocular hemorrhage, optic atrophy or papilledema. Multiple mechanisms of retinal hemorrhage have been postulated, including direct tracking of blood from intracranial hemorrhage, hemorrhage secondary to raised intracranial pressure or retinoschisis A prospective study of children under 2 years of age with head injuries reviewed cases and attempted to determine the sensitivity and specificity of retinal hemorrhage RH in the setting of NAT.
Estimating the probability of abuse Several groups have attempted to develop algorithms to predict the likelihood of NAT. The authors analyzed the probability of abuse if a child under age 3 also had one of the following clinical features: The presence of rib fractures yielded the highest probability of abuse with an odds ratio of 45, and the presence of long-bone fractures yielded an odds ratio of The authors then sought to determine the probability when several features were combined.
They reviewed children with head injuries, 95 of whom were found to be due to abuse. The five variables used in the study include: The specificity, positive predictive value, negative predictive value, and negative likelihood ratio for an AHT clinical prediction rule incorporating these five variables were 0. Physical exam A general and focused physical exam is the starting point for any workup for NAT Figure 2 Findings that raise suspicion are injuries inconsistent with the history, multiple injuries in various stages of healing, or any injuries pathognomonic for abuse, such as cigarette burns 46 Evidence of poor caretaking, sudden onset of mental status changes, bruises on an infant that is not yet cruising, bruises to the pinna, neck or abdomen and any injury to the genitalia should also raise suspicion.
It is important to keep in mind that some findings may be concerning initially but are actually not signs of intentional injury. Intense crying, coughing or retching may cause petechiae on the face and shoulders. Mongolian spots may appear as bruising in the lumbosacral area, and coagulopathies may result in usual bruising Pathologic bone disease e.
Figure 2 Work up for non-accidental trauma NAT. Investigations Laboratory data The Committee on Child Abuse and Neglect addressed the appropriate evaluation for bleeding disorders in the setting of abusive trauma.
The authors stress the importance of obtaining a family history of bleeding disorders as well as a past medical history in assessing for symptoms suggestive of a bleeding disorder, such as epistaxis, excessive bleeding following dental procedures or significant bleeding following circumcision or other surgery. Bleeding disorders which may mimic abuse include coagulation factor deficiencies, fibrinolytic defects, defects of fibrinogen, and platelet disorders.
Mild hemophilia may not cause abnormal aPTT but may still result in significant bleeding after mild trauma. The initial testing panel for intracranial hemorrhage ICH evaluates for conditions for which the probability for the condition resulting in ICH is greater than 1 per 5 million, but does not test for factor XIII deficieincy, vWD, fibrinolytic defects, hypofibrinogenemia and dysfibrinogenemia, as these conditions have either not been associated with intracranial hemorrhage or they are very rarely the cause Skeletal survey A skeletal survey should be obtained in the following groups: In the event that a skeletal survey is negative but the suspicion remains high, a radionucleotide bone scan can be performed.
A skeletal survey may also be repeated days following the injury to reveal healing fractures that may have been missed CT without intravenous contrast remains the imaging modality of choice for evaluating a child with acute neurologic findings or RH on physical examination.
It is more sensitive with regard to acute intracerebral and extra-axial hemorrhages than is magnetic resonance imaging MRIand is also able to diagnose skull and facial fractures. Confirmation that head trauma was inflicted requires multidisciplinary team consensus.
Head trauma cases were identified from the log records of the CAP Team and charts were reviewed in depth. To ensure concurrence, study cases were reviewed by at least 2 of the authors including C. Permission for the anonymous chart review was granted by the hospital's human subjects committee. Information gathered included demographics, social and family data, details of the children's injuries, presenting complaints, clinical course, and details of previous medical visits related to head trauma, if applicable.
We limited the study to children with head injuries who were younger than 3 years for 2 reasons.
- Abusive head trauma
- Mayerson Center for Safe and Healthy Children
First, children older than 3 years are not as likely to sustain severe injury when struck in the head or shaken. Second, children older than 3 years are more likely to be able to articulate their experiences. Hence, AHT is much less likely to be missed as the appropriate diagnosis. Abusive head trauma was defined as inflicted cranial injury. Researchers debate whether shaking alone or shaking and impact cause the signs and symptoms commonly referred to as shaken baby syndrome.
Because shaking, impact to the head, or both are all potentially harmful to infants and toddlers, we grouped all head injuries caused by abuse into the single category of AHT.
Factors considered by the multidisciplinary team in reaching the diagnosis of AHT rather than nonintentional head injury included 1 confession of intentional injury by an adult caretaker; 2 inconsistent or inadequate histories given by caretakers the history given did not explain the nature and severity of the injuries ; 3 associated unexplained injuries, such as fractures or intra-abdominal injuries; and 4 delay in seeking care. Cases of AHT were defined as missed if review of medical records and radiological studies confirmed the following predefined criteria: In all cases, the estimated age of the cranial injuries documented by imaging studies was consistent with the prior time of onset of the child's nonspecific clinical sign s.
All remaining cases of AHT evaluated during the study period were considered recognized. Children who sustained any new inflicted injuries during the period of diagnostic delay were classified as reinjured.
We examined data to determine what factors were associated with a missed vs recognized diagnosis. We then used Wald and likelihood ratio testing to iteratively remove noncontributory variables from the model. Fifty-nine children did not meet study criteria. Of these, 8 were eliminated because they were aged 3 years or older. It was determined that 38 were not abused.
The medical records of 13 children could not be located. The remaining study sample included abused children with head injuries. The mean age of the children was days range, 10 days to 2.
The boys' ages at the time they were first seen for symptoms of AHT were not significantly different than the girls' ages. In our study sample, minorities were overrepresented Many of the children sustained more than 1 type of injury. The remainder had private health insurance. For children with missed AHT, the mean number of physician visits before the trauma was recognized was 2.