MRI Findings in Pediatric Abusive Head Trauma: A Review

Trauma is the most common cause of death and significant morbidity in childhood; abusive head trauma (AHT) is a prominent cause of significant morbidity and mortality in children younger than 2 years old. Correctly diagnosing AHT is challenging both clinically and radiologically. The primary diagnostic challenges are that the abused children are usually too young to provide an adequate history, perpetrators are unlikely to provide truthful account of trauma, and clinicians may be biased in their assessment of potentially abused children. The main radiological challenge is that there is no single imaging finding that is independently specific for or diagnostic of AHT. The radiological evaluation should be based on the multiplicity and severity of findings and an inconsistency with the provided mechanism of trauma. While the most common neuroimaging finding in AHT is subdural hemorrhage, other less well‐known magnetic resonance imaging (MRI) findings such as the “lollipop sign” or “tadpole sign,” parenchymal or cortical lacerations, subpial hemorrhage, cranio‐cervical junction injuries including retroclival hematomas, as well as diffuse hypoxic brain injury have been identified and described in the recent literature. While AHT is ultimately a clinical diagnosis combining history, exam, and neuroimaging, familiarity with the typical as well as the less‐well known MRI findings will improve recognition of AHT by radiologists.     

Diagnosis of Abusive Head Trauma : Neurosurgical Perspective

Abusive head trauma (AHT) is the most severe form of physical abuse in children. Such injury involves traumatic damage to the head and/or spine of infants and young children. The term AHT was introduced to include a wider range of injury mechanisms, such as intentional direct blow, throw, and even penetrating trauma by perpetuator(s). Currently, it is recommended to replace the former term, shaken baby syndrome, which implicates shaking as the only mechanism, with AHT to include diverse clinical and radiological manifestations. The consequences of AHT cause devastating medical, social and financial burdens on families, communities, and victims. The potential harm of AHT to the developing brain and spinal cord of the victims is tremendous. Many studies have reported that the adverse effects of AHT are various and serious, such as blindness, mental retardation, physical limitation of daily activities and even psychological problems. Therefore, appropriate vigilance for the early recognition and diagnosis of AHT is highly recommended to stop and prevent further injuries. The aim of this review is to summarize the relevant evidence concerning the early recognition and diagnosis of AHT. To recognize this severe type of child abuse early, all health care providers maintain a high index of suspicion and vigilance. Such suspicion can be initiated with careful and thorough history taking and physical examinations. Previously developed clinical prediction rules can be helpful for decision-making regarding starting an investigation when considering meaningful findings. Even the combination of biochemical markers may be useful to predict AHT. For a more confirmative evaluation, neuroradiological imaging is required to find AHT-specific findings. Moreover, timely consultation with ophthalmologists is needed to find a very specific finding, retinal hemorrhage.     

Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants

Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.     

Pick's Disease and Head Trauma

Abstract: This is a clinico-pathological study of the relationship between Pick's disease and head trauma. Seven of our autopsied cases with Pick's disease had clinical histories and/or neuropathological evidence of a head trauma. Two cases showed no pathological evidence of traumatic brain damage, although they had clinical histories of a head trauma. The other five cases had old contusions located chiefly on the frontal and temporal bases. As far as we know, there is no reported case of Pick's disease with old contusions in the literature. Therefore, our five cases are of great importance to the study of the relationship between Pick's atrophic processes and traumatic brain damage. The conclusion of our study is that traumatic brain damage involving the atrophy centers of Pick's disease or the adjacent regions could evoke or intensify Pick's atrophic processes.     

Connection and Disconnection in Abusive Relationships

topic . The way in which women's need for connection can lead to destructive relationships in which emotional and physical paralysis is characteristic
purpose . To demonstrate how a woman's sense of disconnection that occurs in abusive relationships may be misinterpreted or worse, labeled and stigmatized, by healthcare providers
source . Theories of growth and development that emphasize how a woman's sense of self and value derive from being able to maintain highly empathic affiliations
conclusion . The behavioral manifestation of disconnection must be understood so that healthcare providers can provide the most effective care possible     

Endotracheal Lidocaine in Preventing Endotracheal Suctioning-induced Changes in Cerebral Hemodynamics in Patients with Severe Head Trauma

Introduction  In patients with severe head trauma, endotracheal suctioning can result in adverse reactions including cough, systemic hypertension, increased intracranial pressure, and reduced cerebral perfusion pressure. The aim of this prospective, blinded clinical trial in mechanically ventilated patients with severe head trauma whose cough reflexes were still intact was to assess the effectiveness of endotracheally instilled lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics (increase in intracranial pressure and reduced cerebral perfusion pressure) after a single endotracheal suctioning. Methods and Results  Ten minutes after lidocaine instillation into the endotracheal tube, secretions were suctioned for <30 s through a standard closed endotracheal suctioning circuit. Heart rate, arterial pressure, intracranial pressure, and cerebral perfusion pressure were continuously monitored. The first patient studied received an endotracheal lidocaine dose of 2.0 mg/kg. The dose for the next study patient was titrated upwards or downwards in 0.5 mg/kg steps according to, whether the intracranial pressure reached the predefined threshold of ≥20 mmHg. A total of 41 patients were studied. Lidocaine instillation into the endotracheal tube had no effect on hemodynamic and ventilatory variables. In 21 patients lidocaine dose instilled into the endotracheal tube effectively prevented the endotracheal suctioning-induced intracranial pressure increase behind the predefined threshold of ≥20 mmHg and cerebral perfusion pressure remained unchanged. In the remaining 20, although intracranial pressure rose significantly cerebral perfusion pressure remained constant. Conclusions  In mechanically ventilated patients with severe head trauma endotracheal lidocaine instillation effectively and dose-dependently prevents the endotracheal suctioning-induced intracranial pressure increase and cerebral perfusion pressure reduction.     

Imaging of Abusive Head Trauma : A Radiologists’ Perspective

Abusive head trauma (AHT) is the most common and serious form of child abuse and a leading cause of traumatic death in infants and young children. The biomechanics of head injuries include violent shaking, blunt impact, or a combination of both. Neuroimaging plays an important role in recognizing and distinguishing abusive injuries from lesions from accidental trauma or other causes, because clinical presentation and medical history are often nonspecific and ambiguous in this age group. Understanding common imaging features of AHT can increase recognition with high specificity for AHT. In this review, we discuss the biomechanics of AHT, imaging features of AHT, and other conditions that mimic AHT.     

Benign Focal Epileptiform Discharges in Children After Severe Head Trauma: Prognostic Value and Clinical Course

Summary: Purpose: To assess the occurrence and prognosis of benign focal epileptiform discharges (BFED) in EEG after severe head trauma (SHT) in children.
Methods: Between January 1987 and December 1994, 47 of 828 children with anamnestic SHT showed a single or dominant epileptic focus in EEG. Spike wave localization and morphology were either suggestive for BFED (group I, 21 children) or were suspected to be symptomatic (group II, 26 children). We analyzed the course of epilepsy and epileptic discharges in EEG, neuroradiologic findings, neurologic outcome, and school adjustment.
Results: After SHT, spike waves appeared immediately (within 72 h) or delayed (maximum 7 years) and disappeared between ages 3 and 14 years in 14 children of group I and between ages 8 and 23 years in 10 of group II. Children with persistent spike waves in group I were all younger than 14 years; in group II, seven were older than 15 years. Computed tomographic (CT) lesions, ipsilateral to the epileptic focus, were seen in 10 children of group I and 15 of group II. Early seizures occurred in nine children of group I and eight of group II and late-onset seizures in one of group I and nine of group II (p = 0.028). Epilepsy developed in three children of group I and 12 of group II and was drug refractory in six children of group II, all with persistent epileptic foci. Regular schools were attended by 14 (67%) children in group I and 12 (48%) of group II.
Conclusions: Benign focal epileptiform discharges in post-traumatic EEGs have the same favorable prognosis as in benign focal epilepsy and should be handled as recommended for classic benign focal epilepsy.     

Abnormal Neuroimaging is Associated with Early In-Hospital Seizures in Pediatric Abusive Head Trauma

Background  

Abusive head trauma (AHT) is a common condition in children. Little is known in this condition regarding the frequency of seizures, the factors associated with increased risk of seizures, or the association of seizures with outcome. We sought to determine frequency and risks for in-hospital seizures after AHT.     

Parturitional Injury of the Head and Neck

Parturitional injuries refer to injuries sustained during and secondary to fetal delivery. The skull, brain, and head and neck regions are frequently involved. Accurate differentiation and classification of the various injuries is essential for treatment, prognosis, and parental counseling. In this review, we discuss the various “bumps and lumps” that maybe encountered along the neonatal skull as well as the most frequent calvarial and intracranial parturitional injuries. In addition, a short discussion of the most common head and neck, facial, and spinal lesions is included. Various mimickers and risk factors are also presented.     

Vasopressors and Propofol Infusion Syndrome in Severe Head Trauma

Introduction  Propofol infusion syndrome (PRIS) is a rare, but lethal complication of high-dose propofol infusions. We undertook this study to evaluate the incidence of PRIS in a cohort of patients with severe head trauma and its relation to the use of vasopressors. Methods  We reviewed all patients with severe head trauma admitted to our Neuro-Intensive Care Unit over a 4-year period for use of propofol and vasopressors. Those patients who developed unexplained acidosis, creatine kinase elevation unrelated to trauma, and electrocardiographic changes were considered having PRIS. We investigated the concomitant use of vasopressors while propofol was used and calculated odds ratios for developing PRIS. Results  We report three adult patients who developed PRIS out of 50 (6%) admitted patients with severe head trauma on propofol infusions. Two of these patients survived and one expired after withdrawal of life support. Concomitant use of vasopressors was associated with development of PRIS in this cohort (odds ratio 29, 95% CI 1.5–581, P < 0.05). Conclusions  Awareness and early recognition of PRIS in critically ill neurosurgical patients on vasopressors and daily screening for creatine kinase elevation, unexplained acidosis, or electrocardiographic changes may reduce the incidence and case-fatality.     

重型颅脑损伤患者血清和脑脊液髓鞘碱性蛋白变化及意义

探讨颅脑损伤患者血清和脑脊液（CSF）中髓鞘碱性蛋白（MBP）含量变化。方法采用酶联免疫吸附法测定了60例重型颅脑损伤患者的血清和CSF中MBP含量。结果患者血清和CSF中MBP含量均增高,其上升水平与脑损伤类型及程度有关。结论同步检测血清和CSF中MBP含量变化,对判断颅脑损伤的程度及类型有一定实用价值。     

Sexually Abusive Behaviour by Children and Adolescents

Recently professionals have recognised that children as well as adults may act in sexually aggressive ways towards others. This is complemented by an expanding empirical evidence base. A comprehensive appraisal of the literature is beyond the scope of this review. However, the estimated size of the problem, it's aetiology ( Lee et al., 2002 ), outcomes and successful intervention programmes ( Borduin & Schaeffer, 2002 ) will be discussed. The evidence base and clinical experience with this group strongly supports the need for coherent government policies in relation to sexually abusive behaviour by children and adolescents.     

Intelligence Patterns Among Children with High-Functioning Autism, Phenylketonuria, and Childhood Head Injury

High-functioning children with autistic-spectrum disorder show the typical pattern of lower Comprehension relative to their own scores on Block Design. This profile is shared, almost exactly, by age- and IQ-matched children with poorer control PKU. Quite distinct profiles are shown by children with better control PKU, who show no difference between Block Design and Comprehension, and by children with head injury involving frontal lobe contusion, who show slightly better Comprehension than Block Design. The data bear on several questions: the relation between Comprehension deficits and language functions measured by Vocabulary; the limits of the advantages conveyed by higher IQ to autistic individuals; whether impaired Comprehension in autism indexes persisting symptoms and/or impairments on theory of mind tasks; the possibility that dopamine deficiency is common to autism and poorer control PKU; and the need for future research aimed at understanding the relations among neurodevelopmental disorders.     

老年人外伤性硬膜下积液的CT诊断(附52例分析)

目的 探讨老年人外伤性硬膜下积液(TSE)的CT诊断,以及与老年性脑萎缩的鉴别要点.方法 福建省平潭县医院外科自2008年3月至2010年3月共收治60岁以上的老年TSE患者52例,回顾性分析患者的临床资料和CT表现,并与同期40例老年性脑萎缩患者的CT征象进行比较.结果 本组患者TSE共91处,其中发生于颞额部31例(34.1%),额部30例(33%);合并老年性脑萎缩34例;首次CT检查发现TSE者32例,首次CT检查阴性而复查发现TSE者20例.短期内复查CT发现积液量增多32例,TSE患者中具有局部脑回变平、脑沟变浅等占位表现者30例,具有"蛛网膜内移征"者9例,而老年性脑萎缩患者CT检查均无上述表现.结论 老年人TSE好发于颞、额部,与老年性脑萎缩的鉴别要点为脑外间隙改变的部位与范围、局部脑回变平脑沟变浅等占位征象、"蛛网膜内移征"、短期CT复查时积液量的变化.

Abstract：

Objective To investigate how to diagnosis traumatic subdural effusion (TSE) and differentiate it with senile encephalatrophy in aged people by CT scan. Methods Fifty-two aged patients with TSE and 40 aged patients with encephalatrophy, admitted to our hospital from March 2008 to March 2010, were chosen in the study. Their clinical data and CT manifestations were retrospectively analyzed and compared. Results Fifty-two patients with TSE had 91 sites of the lesion, including 31 lesions located in temporal-frontal lobe and 30 lesions in frontal lobe. Among the 52 patients, 34 were also noted as having encephalatrophy. First-time CT demonstrated 32 patients with TSE, and the second-time CT on the left patients showed 20 having TSE too. Among the 52 patients, increasing amount of fluid in a short term was noted in 32 patients; local widened gyri with a flattened surface and narrowed sulci was presented in 30; "compressed arachnoid sign" was found in 9. CT results demonstrated that no above-mentioned manifestations were presented in patients with encephalatrophy.Conclusion For aged person, TSE is usually located in the temporal and frontal lobe, and should be differentiated with senile encephalatrophy. The key-points for differentiation include the location and the extent of changes of extra-cerebral space, the space-occupying signs as local flattened gyri and narrowed sulci, the appearing of "compressed arachnoid sign" and the changes of effusion in a short-term review.     

Acute Service Delivery in a Police-Mental Health Program for Children Exposed to Violence and Trauma

The Child Development Community Policing Program represents a national model of community-based collaboration between police and mental health professionals for violence-exposed and traumatized children. Administrative data from clinical records of a 24-hour consultation service were examined through stepwise multivariate logistic regression to identify child and event characteristics associated with a direct, in-person response at the time of police contact. Of 2361 children, 809 (34.3%) received a direct, in-person response. Relative to Caucasian children, Hispanic youth were more likely to receive this form of response (OR = 1.36). An acute clinical response was more likely for incidents of gang involvement (OR = 8.12), accidents (OR = 5.21), felony assaults (OR = 2.97), property crimes (OR = 2.30), family violence (OR = 1.53) and psychiatric crises (OR = 1.29). Acute response was less likely when juvenile conduct problems (OR = 0.61), fires (OR = 0.59), child maltreatment (OR = 0.57), and domestic violence (OR = 0.44) were involved. Incidents that were more severe or involved a primary mental health component were related to utilization of intensive CDCP resources.     

老年外伤性硬膜下积液178例临床分析

外伤性硬膜下积液(traumatic subdural effusion,TSE)又名外伤性硬脑膜下水瘤,常见于颅脑损伤后.颅脑损伤时,脑组织在颅腔内发生较强位移,导致蛛网膜被撕破.脑脊液流到硬脑膜下和蛛网膜之间的硬脑膜下间隙,聚集形成积液.TSE发生率大约为颅脑损伤的1％.其中老年患者发病率更高.TSE诊断和治疗过程较为复杂,常熟市中医院自2006年4月至2011年3月共收治老年重型TSE患者178例,占同期颅脑损伤患者的9.8％,经积极救治后预后较为满意,现报道如下.