Diffusion-weighted magnetic resonance imaging in shaken baby syndrome

doi:10.1016/S0002-9394(01)01366-6

American Journal of Ophthalmology

Volume 133, Issue 2, February 2002, Pages 249-255

Part of this study was presented at the AAPOS meeting (American Association for Pediatric Ophthalmology and Strabismus) in Orlando FL (March 2001) and at the NANOS meeting (North American Neuro-ophthalmology Society) in Palm Springs CA, May 2001.

https://doi.org/10.1016/S0002-9394(01)01366-6 Get rights and content

Abstract

PURPOSE: To evaluate the role of diffusion-weighted magnetic resonance imaging (DWIMRI) in the diagnosis and management of children with suspected or confirmed Shaken Baby Syndrome (SBS).

METHODS: This was a retrospective interventional case series of all infants and children younger than 2 years of age admitted to a children’s hospital. We retrospectively reviewed medical records and neuroimaging findings of all children younger than 2 years of age with confirmed or suspected SBS admitted to a children’s hospital. Inclusion criteria were documented ocular examination by an ophthalmologist and a brain MRI with DWI. Twenty-six infants and children were included. Other children were excluded. Children with proven SBS were diagnosed with “confirmed SBS,” while children in whom the diagnosis of SBS remained uncertain were diagnosed with “suspected SBS.”

RESULTS: Twenty-six infants and children with mean age of 7.1 months (range, 6 weeks–24 months) were included, 18 with confirmed SBS. All 26 patients had a subdural hematoma, 10 had associated occult bone fractures, and 18 had retinal hemorrhages. Seven of the eight cases without retinal hemorrhages had isolated subdural hematoma without parenchymal brain lesions on both conventional MRI and DWIMRI. SBS was confirmed in only one case with a normal fundus. Among the 18 patients with retinal hemorrhages, SBS was confirmed in all but one case. All 18 patients with confirmed SBS had an abnormal DWIMRI. In 13 patients, DWI showed lesions that were larger than on conventional MRI. In patients with brain parenchymal lesions, the DWIMRI characteristics suggested cerebral ischemia, which appears to play a major role in SBS.

CONCLUSIONS: In all patients with confirmed SBS, DWIMRI was abnormal and suggested diffuse or posterior cerebral ischemia, in addition to subdural hematomas in the pathogenesis of this disorder.

Section snippets

Patients

: We retrospectively reviewed the medical records of all infants and children younger than 2 years of age with confirmed or suspected SBS admitted to Children’s Healthcare of Atlanta at Egleston Hospital between 1998 and 2000. Medical records were obtained from the Department of Neurosurgery and from the Department of Pediatric Ophthalmology registry data banks and were cross referenced with the records of the Child Protection Program and neuroradiology referral records to identify suspected

Results

A total of 26 infants and children were included. There were 14 boys and 12 girls with a mean age of 7 months (range, 6 weeks to 24 months). Among these 26 children, 18 had confirmed SBS, and 8 had suspected SBS. All patients had acute subdural hematoma as revealed by CT scanning. Skeletal survey demonstrated long bones or rib fractures in ten cases (38.5%). Retinal hemorrhages were found in 18 patients (69%) (unilateral in 3, bilateral in 15). One case had associated vitreous hemorrhage. All

Discussion

The diagnosis of SBS remains extremely challenging. Although recent successful murder prosecutions have increased public and professional awareness of SBS,27 the syndrome is still missed by physicians.28 Conversely, it is also sometimes overdiagnosed, and some children with subdural hematomas from other causes are erroneously suspected of having SBS and their parents or caregivers falsely accused of assault.27 The consequences of such an error may be grievous.

Injuries to the head pose special

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Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation
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In a study of retinal findings in 159 critically ill children, respiratory failure was associated with a lower likelihood of having RH, and nontraumatic encephalopathy had no association with RH.19 We previously examined the associations between hypoxic ischemic injury, intracranial hemorrhage, and RH severity, but our study did not have any cases of isolated hypoxic brain injury without trauma, so it was not possible to control for potential confounding.20 Strengths of our study include prospective enrollment of patients, ophthalmologist examinations performed through dilated pupils within a short time from cardiac arrest, and careful handling of the potential confounding posed by coincident causes of RH, including consideration of the patterns known to be associated with those causes.
Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest.
This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH.
Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage.
CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.
Two Infant Boys Misdiagnosed as “Shaken Baby” and Their Twin Sisters: A Cautionary Tale
2019, Pediatric Neurology
Virtopsy and Living Individuals Evaluation Using Computed Tomography in Forensic Diagnostic Imaging
2019, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
The names applied to the syndromes of inflicted head injury in infancy reflect the actions necessary to cause the types of injuries seen, such as shaking an infant held by the arms or trunk or forcefully striking an infant's head against a surface.55-59 Nevertheless, in living children, FR-MR should be preferred, for radiation protection issues: The use of diffusion-weighted magnetic resonance imaging allows the evaluation of the role of hypoxic-ischemic injury in traumatic pediatric head injuries.59-61 In conclusion, the indication for FR-CT imaging strongly depends on the applied technique, each of which has its advantages and disadvantages.
The applications of forensic radiology involve both Virtopsy both studies on living people – to demonstrate bone age, search for foreign bodies, such as voluntary injection of drug ovules or surgical sponges accidentally forgotten, to assess gunshot wounds, to evaluate injuries by road accidents, and cases of violence or abuse (both in adults and in children).
Computed tomography is the most used imaging tool used in forensic pathology and its indications are mainly focused on cases of unnatural deaths or when a crime is suspected. It is preferred over the standard autopsy in selected cases, such as in putrefied, carbonized or badly damaged bodies; or as a preliminary evaluation in mass disasters.
Infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion
2018, Journal of the Neurological Sciences
Citation Excerpt :
The clinical and radiological features of the nine patients, therefore, are very similar to those of AESD, and we would call this type of brain injury infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion (TBIRD). Diffuse cerebral ischemia (watershed infarction) was proposed as the pathomechanism of the restricted diffusion in 18 patients with AHT [1], however, this is unlikely because cerebral ischemia usually involves the deep white matter of watershed regions rather than the subcortical white matter. In addition, DWI on day 1 or 2 revealed no restricted diffusion, which is inevitably observed in patients with watershed infarction reflecting cytotoxic edema within 24 h [13].
Reduced diffusion in the subcortical white matter has been reported in some infants with traumatic brain injury (TBI), including abusive head trauma. However, the pathomechanisms of the lesions and clinical features are uncertain. We herein report two infants with TBI who presented with biphasic clinical courses and late reduced diffusion in the subcortical white matter, and reviewed seven clinically and radiologically similar patients with TBI. Their clinical features (secondary neurological symptoms on days 3 to 6) and radiological findings (normal diffusion on days 1 to 2, followed by reduced diffusion on days 3 to 6) are very similar to those observed in patients with acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). MR spectroscopy in one patient revealed a transient increase of glutamine, which is also observed in AESD, suggesting excitotoxicity as a possible pathomechanism.
Post-mortem diffusion MRI of the cervical spine and its nerve roots
2018, Journal of Forensic Radiology and Imaging
The aim of this work is to examine the architectural configuration and the microstructural substrate of the cervical spine and its nerve roots with post-mortem (PM) diffusion tensor imaging (DTI) in non-fixed subjects and to compare these findings with histology.
Magnetic resonance imaging (MRI) data were acquired on a 1.5 T MRI scanner in five non-fixed non-trauma deaths. Two different areas were evaluated: 1) the cervical spinal cord and ventral and dorsal nerve roots with a “high in-plane” DTI and a multi-echo fast field echo protocol, and 2) the cervical peripheral nerves with an “isotropic” DTI and a 3D turbo spin echo protocol. Histology samples were obtained matching the anatomical level of the slices of the ‘high in-plane’ DTI protocol.
We were able to show detailed reconstructions of the dorsal and ventral nerve roots with the ‘high in-plane’ protocol and identified a low fractional anisotropy (FA = 0.30 ± 0.08) in the grey matter and a high FA (0.51 ± 0.13) in the white matter. Both grey and white matter configurations correlated with the anatomical MRI, the diffusion MRI, and with the histological sections. Using the ‘isotropic’ DTI protocol, it was feasible to reconstruct the spinal cord, cervical nerves, and nerve roots in all PM subjects.
We were able to generate detailed architectural configurations of the ventral and dorsal nerve roots. Anatomical and diffusion MR scans showed good qualitative agreement with histology. We believe that PMDTI will be helpful in the assessment of head and neck injuries in a forensic setting.
Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern
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The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36 months with inflicted trauma.
An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36 months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48 h. Variables were compared by t-test and Fisher-exact test.
There were 53 children (median age: five months; range: 1–35 months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p = 0.02), shaking (p = 0.04), lower Glasgow coma score (GCS) (p = 0.01), brain infarcts (p = 0.01), and hypoxic/ischemic injury (p = 0.01) were associated with c-spine injury. One with AOD died. Six had significant disability.
For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging.
Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.

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^☆: This study was supported in part by a departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, New York, and by core grant P30-EY06360 (Department of Ophthalmology) from the National Institutes of Health, Bethesda, Maryland. Dr. Newman and Dr. Lambert are recipients of the Research to Prevent Blindness Lew R. Wasserman Merit Award.

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Original articleDiffusion-weighted magnetic resonance imaging in shaken baby syndrome☆

Abstract

Section snippets

Patients

Results

Discussion

Ophthalmology

Pediatr Neurol

Semin Pediatr

J Pediatr

Childhood injuries in the United States

Am J Dis Child

Nonaccidental head injury in infants—The ‘shaken-baby syndrome’

N Engl J Med

The shaken baby syndrome. A clinical, pathological, and biomechanical study

J Neurosurg

Head injury in very young childrenMechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age

Pediatrics

Long-term outcome in infants with the shaking-impact syndrome

Pediatr Neurosurg

A 12-year ophthalmologic experience with the shaken baby syndrome at a regional children’s hospital

Tr Am Ophthalmol Soc

Nonaccidental head injury in infants‘The shaken baby syndrome revisited.’

Pediatrics Ann

Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children

Pediatrics

Inflicted traumatic brain injuryRelationship of developmental outcome to severity of injury

Pediatr Neurosurg

Prognostic indicators for vision and mortality in shaken baby syndrome

Arch Ophthalmol

Role of apnea in nonaccidental head injury

Pediatr Neurosurg

Reversal sign on CTEffect of anoxic/ischemic cerebral injury in children

Am J Neuroradiol

Cerebrovascular response in infants and young children following severe traumatic brain injuryA preliminary report

Pediatr Neurosurg

Neuropathology of inflicted head injury in children. I. Pattern of brain damage

Brain

Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants

Brain

Original article
Diffusion-weighted magnetic resonance imaging in shaken baby syndrome☆