The acute reversal sign: Comparison of medical and non-accidental injury patients

doi:10.1016/S0009-9260(99)90845-0

Clinical Radiology

Volume 54, Issue 8, August 1999, Pages 495-501

https://doi.org/10.1016/S0009-9260(99)90845-0 Get rights and content

Abstract

OBJECTIVES: (1) To compare the intracranial computed tomography (CT) appearances of patients admitted with various causes of hypoxic ischaemic encephalopathy. Children with known documented accidental trauma were excluded. (2) To compare our results with those in the published literature.

MATERIALS AND METHODS: Seventy-three patients aged between 1 day and 15 years were admitted with clinical features of brain injury and underwent cranial CT. A retrospective review of their medical records and radiology was undertaken. Clinical and radiological data were collected.

RESULTS: On the basis of the combination of the presenting clinical history, progress, outcome, long term follow up and radiology, two groups of patients were identified. Forty-seven children had been the victims of non-accidental injury (NAI). No child in this group had any associated medical condition or any other medical cause for brain injury. All 47 children demonstrated hypoxic ischaemic encephalopathy and had CT signs of cerebral oedema and ‘Reversal Sign’. Intracranial haemorrhage was a highly associated feature. Subdural blood was demonstrated in all 47, acute interhemispheric fissure subdural in 42, intracerebral blood in 16 and intraventricular blood in nine. The remaining 26 children were found to have an identifiable `medical' cause for brain injury. Acute reversal was demonstrated in 21 of this group. Intracranial haemorrhage was uncommon, found in only five and all five had an underlying predisposition to bleeding. No patient in this group demonstrated subdural blood.

CONCLUSION: Non-accidental injury is strongly associated with the finding on CT of intracranial blood, particularly subdural haematoma and interhemispheric fissure bleeding in the presence of hypoxic ischaemic brain injury. The outlook is extremely poor whatever the underlying cause for hypoxic ischaemic brain injury.

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El signo del cerebelo blanco o signo reverso es un hallazgo imagenológico poco frecuente en la tomografía de cráneo; se presenta especialmente en niños con lesiones cerebrales difusas después de un insulto anóxico. Se manifiesta como una disminución difusa de la densidad de los hemisferios cerebrales, con pérdida de la diferenciación de sustancia gris-blanca y un aumento relativo en la densidad del tálamo, el tallo cerebral y el cerebelo bilateral, pero puede no ser simétrico.
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The white cerebellum sign or reversal sign is a rare finding on a head scan imaging, occurring especially in children with diffuse brain injury after a cerebral anoxia. Diffuse manifests as decrease in density of the cerebral hemispheres with loss of differentiation of gray-white matter and a relative increase in the density of the thalamus, brainstem and cerebellum bilateral.
We present the case of a male patient 15 years old who presented an episode of seizures due to poisoning of origin unknown with exogenous substances and simple head scan showed this rare sign.
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Éléments radiologiques. – Trois études rétrospectives portant sur les signes radiologiques des hypoxies graves ont montré l’absence d’HSD chez des enfants avec hypoxie grave dont certains avec arrêt cardiaque prolongé [33,34,142]. Éléments autopsiques.
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In these patients, radiography had a sensitivity of 77% (95% confidence interval [CI] 67%–85%, 75 fractures in 98 patients) for a positive condition on CT. In a series of 47 children who sustained AHT, studied by Rao and colleagues,32 31 (65.9%) did not have a skull fracture. In a study by Merten and colleagues33 among children with AHT, a skull fracture was seen in 45% of cases and intracranial conditions were seen in 56% of children with a skull fracture.
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Fig. 1 summarizes the total number of studies identified and reviewed. Eighteen studies met the inclusion criteria reflecting data on 367 children with iBI.1,6,14,16–30 There were two cross-sectional studies,1,25 and the rest were case series or case studies.
To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).
A systematic review of studies published between 1970–2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.
Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3–33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.
In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.
Reversal sign on ante- and postmortem brain imaging in a newborn: Report of one case
2008, Forensic Science International
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Furthermore, the majority of subdural hematomas in the AI group were unilateral, below the injury site, although they were generally bilateral for NAI. According to Rao et al. [11] and Zimmerman et al. [12], NAI is strongly associated with acute interhemispheric fissure subdural hematoma. The outlook of these newborns or children is extremely poor, whatever the underlying causes of the hypoxic ischemic brain injury.
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2008, American Journal of Preventive Medicine
This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland.
This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period.
The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services.
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Original paperThe acute reversal sign: Comparison of medical and non-accidental injury patients

Abstract

J Paediatrics

Ann Emerg Med

Unrecognised trauma in infants, the battered child syndrome and the syndrome of Ambroise Tardieu

Radiology

Multiple fractures in the long bones of infants suffering from chronic subdural haematoma

Am J Radiol

Whiplash injury and brain damage. An experimental study

J Am Med Assoc

Infantile subdural haematoma and its relationship to whiplash injuries

Br Med J

On the theory and practice of shaking infants

Am J Dis Child

Reversal sign on CT: Effect of anoxic/ischaemic cerebral injury in children

Am J Neuroradiol

Interhemispheric acute subdural haematoma: A computerised tomography manifestation of child abuse by shaking

Neuroradiology

Case Report — necklace calcification — a sign of strangulation

Br J Radiol

Shaken baby syndrome: Inflicted cerebral trauma

Paediatrics

Neuroradiology in Infants and Children

Subdural effusions in infancy: 24 cases

Br Med J

Shaking as a culpable cause of subdural haemorrhage in infants

Med Sci Law

Primary brain trauma in non-accidental injury

Journal of Clinical Pathology

Computed tomography of craniocerebral injury in the abused child

Radiology

Head injury in child abuse: Evaluation with MR imaging

Radiology

Fatal falls in childhood. How far must children fall to sustain fatal head injury? Report of cases and review of the literature. Reiber GD

Am J Forensic Med Pathol

Original paper
The acute reversal sign: Comparison of medical and non-accidental injury patients