Radiographic Evaluation of Inflicted Childhood Neurotrauma Robert A. Zimmerman, M.D. The Children’s Hospital of Philadelphia

Prospective Scottish Study of Child Abuse Incidence 24.6 / 100,000 children Median age 2.2 months M > F Lancet 2000; 356:

Child Abuse Outcomes Mortality Non-accidentalAccidental 13% 2% Arch Pediatr Adolesc Med 2000; 154: 11-15

#Pts%Abuse Chop pediatric ICU % (Admissions 1 year) Mortality5.8%35.3% % Costs for traumatic brain injury with abuse vs. nonabuse (CHOP) = 54%

Risk factors that increase incidence of Child Abuse Younger than 1 year Younger than 1 year Military families Military families Premature infants (less than 28 weeks) Premature infants (less than 28 weeks) Mother less than 18 years Mother less than 18 years Less than 12 years education Less than 12 years education Late prenatal care Late prenatal care Low income Low income Male infant Male infant

Perpetrators of Child Abuse Father Father Boyfriend Boyfriend Female Babysitter Female Babysitter Mother Mother

Minor Trauma Imaging Major Trauma } Child Abuse History

Child Abuse Mechanics of Craniocerebral Trauma Beaten Beaten Shaken Shaken

6 week-old female infant

Inflicted Childhood Neurotrauma Subdural Hematomas 16%, 65%, 67%, 69% Subdural Hematomas Subdural Hematomas Size = 2-15 ml Size = 2-15 ml Usually do not cause Usually do not cause death because of mass effect

NAT 3 month-old male CT FLAIRT2 DWI ASL

Gliding Contusions

Diffuse Brain Swelling in Child Abuse Delay between abuse and time medical attention is sought Delay between abuse and time medical attention is sought

Inflicted Childhood Neurotrauma Swelling/edema/infarction CT, MRI 15.6%, 34.5%, 71%, 77.7% Diffusion 69%, 89% Death = ICP

Diffusion Weighted Imaging in Non- Accidental Head Injury: Acute Injury Patterns Diffuse Supratentorial Injury13 Watershed Supratentorial12 Infratentorial(2) Venous Occlusion 4 Diffuse Axonal Injury 2 Gliding Contusion 2

Diffuse Supratentorial Injury T2Diffusion

Diffusion Weighted Imaging in Non- Accidental Head Injury: Acute Injury Patterns 1.CT is the initial imaging modality in child abuse, however, while adequate for acute and chronic subdurals and gross advanced brain swelling, CT misses early cytotoxic edema and fails to give much information regarding mechanisms of injury. 2.MRI without diffusion is useful for subdurals, old, subcute and new, and for brain injury. 3.MRI diffusion imaging is very sensitive to acute brain injury and gives information regarding likely mechanism of injury.

Strangulation, Suffocation & Asphyxia 2,178 cases in 1995 in infants 29 / 100,000 children Arch Pediatr Adolesc Med 1997; 151: 72-77

Strangulation

Starvation

Retinal Hemorrhage

Cranio-Cervical Injury FAT SAT T2

Child Abuse Clinical misdiagnosis of child abuse as: 1.Accidental trauma 2.Gastroenteritis, viral 25% suffer further injury before correct diagnosis is made.

Questions 1.How sensitive are our diagnostic studies in recognizing non-accidental trauma? 2.What is frequency of various injuries in non-accidental trauma? 3.Can we differentiate non-accidental from accidental injuries? 4.Timing of onset and evolution of injuries on imaging studies – Are there reliable criteria?