Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma

Abstract

PurposeChild abuse is a leading cause of death in infants, which is often associated with abusive head trauma (AHT). The purpose of this retrospective analysis was to identify ocular and systemic findings in confirmed cases of AHT and compare them to a group of non-abusive head trauma (NAHT) patients.Patients and methodsA retrospective chart review of 165 patients with accidental and non-accidental trauma admitted between 2013 and 2015 to Children’s Hospital and Medical Center in Omaha, NE, USA, was performed. Diagnosis of AHT was made after the analysis of ocular and systemic findings by various subspecialists. The NAHT group consisted of accidental trauma, abusive trauma without significant apparent head involvement on initial evaluation and unconfirmed AHT cases.ResultsOf the 165 presenting cases, 30 patients were diagnosed with AHT and 127 were diagnosed with NAHT. Ocular findings in AHT patients were significant for retinal hemorrhages (63%) and vitreous hemorrhages (37%), while NAHT patients had no ocular findings (p<0.001). Neuroimaging revealed subdural hemorrhages (SDHs) in 29 out of 30 AHT patients (97%) and in 27 out of 127 NAHT patients (21%). Seizures were present in 43% of AHT patients (n=13) and only in 8% of NAHT patients (n=10).ConclusionAHT has statistically significant findings of retinal and vitreous hemorrhages. The absence of diffuse retinal hemorrhages, however, does not preclude the AHT diagnosis as more than one-third of AHT patients lacked retinal hemorrhages. SDHs, loss of consciousness and history of seizures also have high correlation with a diagnosis of AHT.

Determining the Tractional Forces on Vitreoretinal Interface Using a Computer Simulation Model in Abusive Head Trauma

“…[58][59][60] , Suh and associates showed that infants delivered vaginally without complication may present with RH up to 50% of the cases, but most of these cases have only preretinal and intraretinal hemorrhages in the posterior pole with no signs of retinoschisis and vitreous hemorrhage that can be associated with vitreoretinal separation. 50,51 Furthermore, most of these RHs resolved within a few weeks, although a few isolated cases lasted up to 3 months of age. 50,51 The present FE model may shed light on pathophysiology of the RH patterns and differentiating findings in AHT from other causes.…”

“…In contrast to our model predictions for shaking, in cases of increased intracranial pressure with cerebral edema or compressive subdural hematoma, increases in retinal venous pressure and axoplasmic transport interference of ganglion cell layers can result in peripapillary hemorrhages localized to the posterior pole with mostly intraretinal hemorrhages. 46,[50][51][52][53][54][55][56][57] RH in AHT cases commonly show multilayered and diffuse RH involving the peripheral retina in addition to the macular area. [58][59][60] , Suh and associates showed that infants delivered vaginally without complication may present with RH up to 50% of the cases, but most of these cases have only preretinal and intraretinal hemorrhages in the posterior pole with no signs of retinoschisis and vitreous hemorrhage that can be associated with vitreoretinal separation.…”

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center

“…Retinal injuries were found to be highly specific for NAT in this study. Retinal injuries have historically been a hallmark of NAT, often due to sheering forces experienced in abusive head trauma [ 5 , 10 , 11 ]. Only one case of accidental trauma from a fall resulted in a retinal injury in this study.…”

“…Cerebral injuries should still be flagged for suspicion of NAT because they were still present in 37.5% of the cases. In addition, abusive head trauma (AHT) has been shown in other studies to be one of the most common types of NAT and the most morbid and potentially fatal [ 4 , 5 , 10 , 11 ].…”

Pediatric Abusive Head Trauma: A Systematic Review

“…Thiblin [41] National study shows that abusive head trauma mortality in Sweden was at least 10 times lower than in other Western countries X X Morgan et al [42] Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma X X Gencturk et al [43] Various cranial and orbital imaging findings in pediatric abusive and non-abusive head trauma, and relation to outcomes X X Sidpra et al [44] Skull fractures in abusive head trauma: A single centre experience and review of the literature X Wright et al [45] Disability and visual outcomes following suspected abusive head trauma in children under 2 years X Donaldson et al [46] Ophthalmology referral as part of a multidisciplinary approach to suspected abusive head trauma X Payne et al [47] Recognition and nursing management of abusive head trauma in children X X…”