1. Neuroimaging findings in abusive head trauma Giulio Zuccoli, Ashok Panigrahy and Rechel Berger 1 Department of Radiology, Safar Resuscitation Center 1, Child Abuse Advocacy, Children’s Hospital of UPMC Pittsburgh,

2. NAT: What is it? The most common cause of death from child abuse Leading cause of death from TBI in children <1 yr old Children aged 0-3 years are most likely to experience abuse Mild NAT may be up to 150x more common (Theodore et al, Pediatrics) Conservatively, about 2,000 cases/yr in the U.S.

3. Older children with AHT at Children’s Hospital of Pittsburgh From 2005-2008, 36% of children were >1yr

4. Less than 1/3 of children have the traditional triad of brain injury, retinal hemorrhages and fractures

6. Retinal hemorrhages Retinal hemorrhage, unilateral or bilateral, often extending to the periphery and in multiple layers of the retina/retinoschisis Subconjunctival hemorrhages

7. Neuroimaging Diagnose clinically unsuspected NAT Diagnose clinically unsuspected NAT Determination of timing Determination of timing Document the nature and extent of NAT Document the nature and extent of NAT Diagnose conditions requiring immediate treatment Diagnose conditions requiring immediate treatment

8. Rotational acceleration Is associated with: Diffuse axonal injury (DAI)  disruption of axons Diffuse axonal injury (DAI)  disruption of axons Tearing of bridging veins  Subdural hematoma Tearing of bridging veins  Subdural hematoma Subarachnoid hemorrhage Subarachnoid hemorrhage Retinal hemorrhage Retinal hemorrhage

9. Impact loading injuries Focal strains at the site of impact Focal strains at the site of impact Pressure waves in the brain Pressure waves in the brain Are associated with Scalp hematoma Scalp hematoma Skull fracture Skull fracture SDH/SAH SDH/SAH Brain contusion Brain contusion

10. Shear Injury (DAI): The brain deforms readily in response to shear stress. Brain mostly shears at the gray-white junction. Contusion: Cerebral contusion is a focal hemorrhage within the brain parenchyma resulting from direct contact forces. Cerebral Edema: Edema, focal or diffuse, is a common in NAT. It may be injury-related or hypoxia-related, being observed in suffocation, strangulation, post traumatic apnea.

11. 3D reconstruction with a right parietal diastatic fracture.

12. Reversal sign Han BK et al AJNR 1989;10:1191–1198. Kavanagh EC. Radiology. 2007;245:914-5. Hypoxia/anoxia (drawoning, status epilepticus, asphyxia) Infection (encephalitis/meningitis) Trauma

14. Extraaxial Hemorrhage NAT Epidural hematoma is not a specific sign of NAT NAT SDH 46% (NAT) vs 10% (AT) NAT SAH 31% (NAT) vs 8% (AT) Reece RM, Sege R. Arch Pediatr Adolesc Med 2000; 154:11–15.

16. Subdural 6 m old male (NAT) SDH

18. 3-weeks-old female day 9 after trauma

19. 1 month FU

21. Conventional 2D GRE 3D SWI

22. DWI in combination with ADC mapping allows better delineation of the degree of white matter involvement than conventional MRI Patients showing evidence of global abnormalities on DWI suffer from severe cognitive or motor deficits DWI may show additional areas of injury vs conventional MRI sequences in 25% of patients DWI\ADC Suh DY et al Neurosurgery 2002;49,309-320.

24. Specificity: overlap with post ischemic spectrum

25. Spine, when? Lumbar kyphosis, thoraco-lumbar swelling, focal neurological signs Spine: findings Fractures (Hangman’s, compression, dislocation), Cord lesions, SDH, EH

28. Summary SDH/SAH - often thin - often bilateral frontoparietal or interhemispheric, often without a skull fx Cerebral edema Diffuse axonal injury (DAI) Spinal lesions, SDH, EH No single finding is diagnostic of NAT No single finding is diagnostic of NAT Findings are always in the context of the history Findings are always in the context of the history