Abusive Head Trauma diagnosis
Characteristic findings include retinal hemorrhages, subdural hematomas (bilateral in 80%), and/or subarachnoid hemorrhage (SAH). There are usually few or no external signs of trauma (including cases with impact, although findings may be apparent at autopsy). In some cases, there may be finger marks on the chest, multiple rib fractures, and/or pulmonary compression ± parenchymal lung hemorrhage. Deaths in these cases are almost all due to uncontrollable intracranial hypertension. There may also be an injury to the cervicomedullary junction.
Radiology provides valuable information for this challenging diagnosis, but no single neuroimaging finding is independently diagnostic of abusive head trauma.
The classic triad of Abusive Head Trauma is subdural hematoma, cerebral edema and retinal hemorrhage.
The medical rationale for the diagnosis of AHT has a significant impact on the judicial decision-making process to determine evidence of child abuse, enabling collaboration with the police, prosecutors, and other investigative agencies, including lawyers.
Medical personnel involved in neurosurgical emergencies have an important responsibility as a safety network for pediatric care and are expected to play a central role in the diagnosis of AHT through collaboration with many specialized departments.
Retinal hemorrhages
Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies 1).
see Corbiceiro WCH, Silva TL, Correia RS, de Vasconcelos MM, Corrêa DG. Magnetic resonance imaging features of retinal hemorrhage in abusive head trauma. Childs Nerv Syst. 2022 Nov 11. doi: 10.1007/s00381-022-05743-w. Epub ahead of print. PMID: 36369384.
Skull fracture
During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December 2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism 2).