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• First, do no harm
  Minoo Irani
  Published on: 9 January 2022
• Cranial Ultrasound As Non-Invasive Diagnostic Technique In The Diagnosis Of The Subdural Haemorrhage
  Ahmet Sert
  Published on: 9 January 2022

• Published on: 9 January 2022

  First, do no harm

  • Minoo Irani, Consultant Community Paediatrician

  Dear Editor,

  The article by Dr Datta and colleagues makes interesting reading. The importance of optimal neuroimaging and accurate interpretation of scans is correctly emphasised. Their first recommendation about neuroimaging in all suspected cases of non-accidental head injury (NAHI)is welcome and the point about MRI as a second line investigation contributing to prognostication in these cases has some evidence bas...

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  Dear Editor,

  The article by Dr Datta and colleagues makes interesting reading. The importance of optimal neuroimaging and accurate interpretation of scans is correctly emphasised. Their first recommendation about neuroimaging in all suspected cases of non-accidental head injury (NAHI)is welcome and the point about MRI as a second line investigation contributing to prognostication in these cases has some evidence base. However, I have reservations about the evidence available to support their second and third recommendations.

  The recommendation for a head CT scan to be performed as part of 'skeletal survey' for children under 6 months of age where physical abuse is suspected may have the consensus of a group of respected neuroradiologists, but little good quality evidence to support it. By the time the authors reach their third recommendation of a CT scan to be strongly considered as part of a skeletal survey in any child being investigated for physical abuse, any attempt to support this with evidence is also lost.

  So what are the dangers of using neuroradiology as a potential 'screening tool' for selective screening of 'high-risk' cases, as the recommendations seem to suggest? Even if we ignore the false-negatives (one can argue that the diagnosis would be missed anyway if these cases did not get the scans), the issue of inconclusive/suspicious findings on CT scans remains. It is inevitable that the majority of these suspicious findings will then need to be confirmed or rejected by performing an MRI scan. If by that time the physical injury with which the infant/child presented first was considered to be accidental, few professionals would be willing to support this position if they were aware that the CT findings were not entirely normal. Only after the MRI was reliably reported by a neuroradiologist, would the child protection investigation be reliably concluded. The emotional stress of something possibly being abnormal in their child's brain would be encountered by numerous such parents, in addition to the stress of child protection procedures. Practical issues such as CT radiation, waiting times for MRI and above all, the workload for a very small number of experienced neuroradiologists having to report a large number of such scans cannot be ignored. The potential for legal challenges, possible miscarriages of justice and conflicting opinions from expert witnesses is unlikely to help making child protection work popular among Paediatricians.

  I do not intend to discredit these recommendations. We simply need to convince ourselves that they will truly benefit children.

  Publication of these recommendations in a journal widely read by Paediatricians in the UK, could lead some to believe that these recommendations have broad agreement among paediatricians and approval from the RCPCH. After all, these recommendations are part of the standard for skeletal surveys in suspected NAI in children (website of the British Society of Paediatric Radiology) [1] and are being widely disseminated at Paediatric Educational meetings.[2] Maybe we should wait for the RCPCH to appraise these recommendations before we incorporate them into our daily practice.

  References

  1. http://www.bspr.org.uk

  2. 6th Nottingham Paediatric Symposium: Non-accidental injury. Diagnostic and Legal Aspects (17,18 June 2004).

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  Cranial Ultrasound As Non-Invasive Diagnostic Technique In The Diagnosis Of The Subdural Haemorrhage

  • Ahmet Sert, Assistant of Professor
  • Other Contributors:
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  Dear Editor,

  Cranial Ultrasound As Non-Invasive Diagnostic Technique In The Diagnosis Of The Subdural Haemorrhages I read with interest the original article entitled “Neuroradiological aspects of subdural haemorrhages” in the Arch Dis Child 2005;90:947–95. Datta et al. undertook a retrospective analysis of 74 patients under the age of 2 years with subdural haemorrhage or subdural effusion diagnosed between 1992 and...

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  Dear Editor,

  Cranial Ultrasound As Non-Invasive Diagnostic Technique In The Diagnosis Of The Subdural Haemorrhages I read with interest the original article entitled “Neuroradiological aspects of subdural haemorrhages” in the Arch Dis Child 2005;90:947–95. Datta et al. undertook a retrospective analysis of 74 patients under the age of 2 years with subdural haemorrhage or subdural effusion diagnosed between 1992 and 2001.1 They described that ultrasound was performed before computed tomography in 12 cases; subdural haemorrhages were not seen in seven of these. However, ages of the patients ultrasound performed were not presented. Datta et al. suggested that ultrasound has no role in excluding a subdural haemorrhage, even in experienced hands, but may be used to monitor resolution of subdural haemorrhage diagnosed on computed tomography /magnetic resonanse imaging and in looking for subtle shearing lesions at grey-white interface. I believe that it can not be generalized about the capacity of cranial ultrasound because the numbers of the patients in their retrospective study were less, and that the mean ages of patient groups were important for choosing imaging tecnique. On the other hand, in an epidemiological study by Hobbs et al. the definition used was ‘‘any child under 2 years at diagnosis with subdural haemorrhage, haematoma, or effusion of any severity, arising from whatever cause and diagnosed on computed tomography, magnetic resonanse imaging, or ultrasound scan or at postmortem examination’’. This study was the largest study of subdural haemorrhage in infancy in the UK.2 Cranial ultrasound scan was a diagnostic technique in the diagnosis of the subdural haemorrhage according to this study. However, Gaevyi et al. examined 275 children with acute craniocerebral trauma. And various types of intracranial hemorrhages and contusions of the brain were differentiated by means of cranial ultrasonography. They concluded that cranial ultrasonography is a highly informative diagnostic method, particularly in infancy, which makes it possible to visualize the craniocerebral injuries and study them continuously during treatment. Intraoperative ultrasound was conducted in older children with suspected intracranial hematoma, which allowed the pathological process to be clearly located.3 Advanced cranial ultrasound techniques such as high resolution ultrasound and colour-doppler sonography may give useful prognostic information at relatively early stages following the injury. Rupprecht et al. concluded that high resolution ultrasound and colour-doppler sonography are able to reliably differentiate between a subdural and a subarachnoid fluid collection.4 I think that both the diagnosis and the follow-up of subdural haemorrhage can be made by means of cranial ultrasonography, and that ultrasound is a reliable non-invasive, cheap method for assessing subdural haemorrhages in infancy, especially in newborn period. This assessment approach might have the potential to be developed in to a valid radiological assessment tool. Nevertheless, more studies are needed before any conclusion can be drawn.

  Correspondence to:

  Ahmet Sert

  Selcuk Universitesi Meram Tip Fakultesi
  Cocuk Sagligi ve Hastaliklari
  42080 Konya
  Turkey

  Tel: 00. 90. 332. 223 63 50
  Fax: 00. 90. 332. 223 61 81

  E-mail: ahmetsert2@hotmail.com

  References:

  1. Datta S, Stoodley N, Jayawant S, et al. Neuroradiological aspects of subdural haemorrhages. Arch Dis Child 2005;90:947–51.

  2. Hobbs C, Childs A-M, Wynne J, et al. Subdural haematoma and effusion in infancy: an epidemiological study. Arch Dis Child 2005;90:952–5.

  3. Gaevyi OV, Artarian AA, Korolev AG. Ultrasonography of the brain in children with craniocerebral trauma. Zh Vopr Neirokhir Im N N Burdenko 1991;4:16-9.

  4. Rupprecht T, Lauffer K, Storr U, et al. Extra-cerebral intracranial fluid collections in childhood: differentiation between benign subarachnoid space enlargement and subdural effusion using color-coded duplex ultrasound. Klin Padiatr 1996;208(3):97-102.

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  Conflict of Interest:
  None declared.

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