Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse

Vinchon, Matthieu; Noulé, Nathalie; Tchofo, P. Jissendi; Soto-Ares, Gustavo; Fourier, C.; Dhellemmes, P

doi:10.3171/ped.2004.101.2.0044

Cited by 32 publications

(44 citation statements)

References 31 publications

(24 reference statements)

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“…31 Several authors have hypothesized that mixed-density SDH may reflect an admixture of fresh clotted blood, unclotted blood or serum, and/or CSF from the subarachnoid space that has migrated into the subdural space through a tear in the arachnoid membrane. 9,11,33,39 A communication between the subarachnoid and subdural spaces in infants with SDH was confirmed in one study by injecting a radioisotope into the CSF via lumbar puncture at the time of subdural drain placement and identifying the radioisotope within the subdural fluid within 3-24 hours. 39 It is apparent that although mixed-density SDHs are more common after AHT, and some of these likely represent acute and prior injuries, the fact that they are also present early after presumably single accidental injuries makes their interpretation more difficult.…”

Section: Serial Changes On Ctmentioning

confidence: 99%

“…9 In another study of 18 infant victims of motor vehicle crashes with SDH, 3 infants had mixed-density SDH on the initial CT scan. 32 Although mixed-density SDH has been identified both following accidental and nonaccidental injuries, 31,33 it appears to be significantly more common following AHT. 31 In a recent study comparing witnessed accidental injuries with confessed cases of AHT, Vinchon and colleagues reported mixed-density SDH on the initial imag- Fig.…”

Section: Serial Changes On Ctmentioning

confidence: 99%

“…Homogeneously hyperdense SDH was present in fewer than one-third of our cases; mixed-density SDH, containing both hyperdense and hypodense components, was present in over half of the infants in the present study, in onethird of children in our prior study, 9 and in 91% of infants with AHT in a third study by Vinchon et al 31 Mixeddensity SDH in AHT has been interpreted as prima facie evidence of serial injuries, 6,25 but this concept has recently been challenged. 9,11,32,33,39 One child in our previous study developed a hypodense subdural collection de novo on a second CT scan performed 19 hours after an initial scan showed no SDH in that region. 9 In another study of 18 infant victims of motor vehicle crashes with SDH, 3 infants had mixed-density SDH on the initial CT scan.…”

Section: Serial Changes On Ctmentioning

confidence: 99%

“…In a smaller study of 20 children with accidental and nonaccidental injuries, some hyperdensity was present in the SDH on all CT scans performed within 1 week postinjury but not on scans performed after Day 11. 33 …”

Section: Serial Changes On Ctmentioning

confidence: 99%

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Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

Bradford¹,

Choudhary²,

Dias

2013

PED

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Object The appearance and evolution of neuroimaging abnormalities following abusive head trauma (AHT) is important for establishing the time frame over which these injuries might have occurred. From a legal perspective this frames the timing of the abuse and therefore identifies and excludes potential perpetrators. A previous pilot study involving 33 infants with AHT helped to refine the timing of these injuries but was limited by its small sample size. In the present study, the authors analyzed a larger group of 210 cases involving infants with AHT to chronicle the first appearance and evolution of radiological (CT, MRI) abnormalities. Methods All children younger than 24 months admitted to the Penn State Hershey Medical Center with AHT over a 10-year period were identified from a medical record review; the time of injury was determined through an evaluation of the clinical records. All imaging studies were analyzed, and the appearance and evolution of abnormalities were chronicled on serial neuroimaging studies obtained in the days and weeks after injury. Results One hundred five infants with specific injury dates and available imaging studies were identified; a subset of 43 children additionally had documented times of injury. In infants with homogeneously hyperdense subdural hematomas (SDHs) on initial CT scans, the first hypodense component appeared within the SDH between 0.3 and 16 days after injury, and the last hyperdense subdural component disappeared between 2 and 40 days after injury. In infants with mixed-density SDHs on initial scans, the last hyperdense component disappeared between 1 and 181 days. Parenchymal hypodensities appeared on CT scans performed as early as 1.2 hours, and all were visible within 27 hours after the injury. Rebleeding into SDHs was documented in 17 cases (16%) and was always asymptomatic. Magnetic resonance imaging of the brain was performed in 49 infants. Among those with SDH, 5 patterns were observed. Patterns I and II reflected homogeneous SDH; Pattern I (T1 hyperintensity and T2/FLAIR hypointensity, “early subacute”) more commonly appeared on scans performed earlier after injury compared with Pattern II (T1 hyperintensity and T2/FLAIR hyperintensity, “late subacute”), although there was considerable overlap. Patterns III and IV reflected heterogeneous SDH; Pattern III contained relatively equal mixtures having different intensities, whereas Pattern IV had fluid that was predominantly T1 hypointense and T2/FLAIR hyperintense. Again, Pattern III more commonly appeared on scans performed earlier after injury compared with Pattern IV, although there was significant overlap. Conclusions These data extend the preliminary data reported by Dias and colleagues and provide a framework upon which injuries in AHT can be timed as well as the limitations on such timing estimates.

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Section: Serial Changes On Ctmentioning

confidence: 99%

Section: Serial Changes On Ctmentioning

confidence: 99%

Section: Serial Changes On Ctmentioning

confidence: 99%

Section: Serial Changes On Ctmentioning

confidence: 99%

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Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

Bradford¹,

Choudhary²,

Dias

2013

PED

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“…While cSDHs in infants are rare and rather implicate a delayed and nonacute process, SDHys may develop rapidly or be delayed. Accordingly, early hypodensity in infantile SDH has also been observed by others 51,[98][99][100] arguing against an overhasty diagnosis of a chronic process but suggesting a significant role of CSF.…”

Section: Discussionmentioning

confidence: 91%

Subdural Hygromas in Abusive Head Trauma: Pathogenesis, Diagnosis, and Forensic Implications

Wittschieber¹,

Karger²,

Niederstadt

et al. 2014

AJNR Am J Neuroradiol

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SUMMARY:Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan. ABBREVIATIONS:AHT ϭ abusive head trauma; BESS ϭ benign enlargement of subarachnoid space; BV ϭ bridging vein; cSDH ϭ chronic subdural hematoma;

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Non‐Sexual Abuse in Children

Minns¹,

Madea²,

Kernbach-Wighton³

2014

Handbook of Forensic Medicine

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Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse

Abstract: The authors propose a method by which to develop a time scale for the dating of head injuries in infants based on the modifications of signal and location of blood on CT and MR images.

Cited by 32 publications

References 31 publications

Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

Serial neuroimaging in infants with abusive head trauma: timing abusive injuries

Subdural Hygromas in Abusive Head Trauma: Pathogenesis, Diagnosis, and Forensic Implications

Non‐Sexual Abuse in Children

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