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Pediatric Radiology Aug 2018Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history,... (Review)
Review
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
Topics: Child; Child Abuse; Child, Preschool; Consensus; Craniocerebral Trauma; Hematoma, Subdural; Humans; Infant; Infant, Newborn; Retinal Hemorrhage; Rib Fractures; Societies, Medical; Spinal Injuries
PubMed: 29796797
DOI: 10.1007/s00247-018-4149-1 -
Radiology Jan 2021Background Subdural hemorrhage (SDH) is thought to have a benign course in asymptomatic neonates. However, effects on neurodevelopmental outcomes have not been...
Background Subdural hemorrhage (SDH) is thought to have a benign course in asymptomatic neonates. However, effects on neurodevelopmental outcomes have not been established. Purpose To evaluate neurodevelopmental outcomes, gray matter volumes, and MRI findings in asymptomatic neonates with SDH compared with control neonates. Materials and Methods This retrospective analysis was conducted between 2003 and 2016 and was based on data from the University of North Carolina Early Brain Development Study. Neurodevelopmental outcomes were evaluated at 2 years of age by using the Mullen Scales of Early Learning (MSEL). All infants were imaged with 3.0-T MRI machines and were evaluated for SDH at baseline (neonates) and at ages 1 and 2 years. Volumetric MRI for brain segmentation was performed at ages 1 and 2 years. A secondary analysis was performed in neonates matched 1:1 with control neonates. Differences in categorical variables were measured by using the Fisher exact test, and the test was used for continuous variables. Results A total of 311 neonates (mean gestational age ± standard deviation, 39.3 weeks ± 1.5), including 57 with SDH (mean gestational age, 39.5 weeks ± 1.2), were evaluated. The subgroup included 55 neonates with SDH (mean gestational age, 39.6 weeks ± 1.2) and 55 matched control neonates (mean gestational age, 39.7 weeks ± 1.2). Fifty-five of 57 neonates with SDH (97%; 95% CI: 92, 100) were delivered vaginally compared with 157 of 254 control neonates (62%, 95% CI: 56, 68; < .001). Otherwise, there were no differences in perinatal, maternal, or obstetric parameters. There were no differences in composite MSEL scores (115 ± 15 and 109 ± 16 at 2 years, respectively; = .05) or gray matter volumes between the neonatal SDH group and control neonates (730 cm ± 85 and 742 cm ± 76 at 2 years, respectively; = .70). There was no evidence of rebleeding at follow-up MRI. Conclusion Neurodevelopmental scores and gray matter volumes at age 2 years did not differ between asymptomatic neonates with subdural hemorrhage and control neonates. © RSNA, 2020
Topics: Child, Preschool; Female; Follow-Up Studies; Gray Matter; Hematoma, Subdural; Humans; Infant, Newborn; Magnetic Resonance Imaging; Male; Organ Size; Retrospective Studies
PubMed: 33107801
DOI: 10.1148/radiol.2020201857 -
Medical Hypotheses Nov 2020We present the hypothesis that subdural hemorrhages during childbirth might be associated with so-called three-month colic, whereby an infant cries intensively and...
We present the hypothesis that subdural hemorrhages during childbirth might be associated with so-called three-month colic, whereby an infant cries intensively and repeatedly during its first three months. A traditional interpretation is that this infantile crying is associated with nutrition and is accordingly "a gut issue", but this is probably not the whole explanation. It has also been suggested that infantile crying can trigger a caregiver to shake the baby to make it stop crying, thereby inflicting a subdural hemorrhage. A mechanism-based argument supporting our hypothesis would be that the bilateral film-thin subdural hemorrhage associated with a high percentage of deliveries might cause meningeal irritation and in some cases also symptoms as inconsolable crying. An epidemiological argument is that infantile crying is more frequent among first-born, male and premature babies; these categories have also an increased incidence of subdural hemorrhage. Moreover, preventive programs for managing infantile crying have had no effect on the incidence of alleged shaken baby cases. As infantile crying is currently considered unexplained, it is reasonable to explore the proposed hypothesis and strategies which refute or corroborate it. We suggest that a cohort study of premature, first born and male babies with and without infantile crying are examined with brain MRI scan soon after delivery with clinically and MRI follow up during 3-6 months.
Topics: Caregivers; Cohort Studies; Colic; Crying; Hematoma, Subdural; Humans; Infant; Male
PubMed: 33254567
DOI: 10.1016/j.mehy.2020.110256 -
Stroke May 2020Background and Purpose- The risk of arterial ischemic events after subdural hemorrhage (SDH) is poorly understood. This study aimed to evaluate the risk of acute...
Background and Purpose- The risk of arterial ischemic events after subdural hemorrhage (SDH) is poorly understood. This study aimed to evaluate the risk of acute ischemic stroke and myocardial infarction among patients with and without nontraumatic SDH. Methods- We performed a retrospective cohort study using claims data from 2008 through 2014 from a nationally representative sample of Medicare beneficiaries. The exposure was nontraumatic SDH. Our primary outcome was an arterial ischemic event, a composite of acute ischemic stroke and acute myocardial infarction. Secondary outcomes were ischemic stroke alone and myocardial infarction alone. We used validated , , diagnosis codes to identify our predictor and outcomes. Using Cox regression and corresponding survival probabilities, adjusted for demographics and vascular comorbidities, we computed the hazard ratio in 4-week intervals after SDH discharge. We performed secondary analyses stratified by strong indications for antithrombotic therapy (composite of atrial fibrillation, peripheral vascular disease, valvular heart disease, and venous thromboembolism). Results- Among 1.7 million Medicare beneficiaries, 2939 were diagnosed with SDH. In the 4 weeks after SDH, patients' risk of an arterial ischemic event was substantially increased (hazard ratio, 3.6 [95% CI, 1.9-5.5]). There was no association between SDH diagnosis and arterial ischemic events beyond 4 weeks. In secondary analysis, during the 4 weeks after SDH, patients' risk of ischemic stroke was increased (hazard ratio, 4.2 [95% CI, 2.1-7.3]) but their risk of myocardial infarction was not (hazard ratio, 0.8 [95% CI, 0.2-1.7]). Patients with strong indications for antithrombotic therapy had increased risks for arterial ischemic events similar to patients in the primary analysis, but those without such indications did not demonstrate an increased risk for arterial ischemic events. Conclusions- Among Medicare beneficiaries, we found a heightened risk of arterial ischemic events driven by an increased risk of ischemic stroke, in the 4 weeks after nontraumatic SDH. This increased risk may be due to interruption of antithrombotic therapy after SDH diagnosis.
Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Brain Ischemia; Female; Hematoma, Subdural; Hemorrhage; Humans; Ischemia; Male; Middle Aged; Myocardial Infarction; Retrospective Studies; Risk Factors; Stroke
PubMed: 32178587
DOI: 10.1161/STROKEAHA.119.028510 -
Medicine Nov 2022The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use...
The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.
Topics: Humans; Aged; Retrospective Studies; Hematoma, Subdural, Acute; Hematoma, Subdural; Drainage; Craniotomy
PubMed: 36401411
DOI: 10.1097/MD.0000000000031621 -
Forensic Science, Medicine, and... Jun 2019Some authors have suggested that in the fetus, neonate and infant, intradural hemorrhage (IDH) is relatively common and often presents alongside subdural hemorrhage...
Some authors have suggested that in the fetus, neonate and infant, intradural hemorrhage (IDH) is relatively common and often presents alongside subdural hemorrhage (SDH). These authors have theorized that pediatric SDH may result from an IDH due to blood leakage from a dural vascular plexus. In this study, we report the inter-observer variation for detection of IDH from a retrospectively collected series of pediatric autopsy photographs, with and without SDH. Autopsy photographs of the falx and tentorium from 27 neonatal, infant and early childhood autopsies were assessed by two independent consultant forensic pathologists blinded to all case histories for the presence and extent (focal or diffuse) of IDH. Inter-observer agreement between the pathologists was calculated using Cohen's kappa coefficient. The occurrence of subdural hemorrhage was also recorded at autopsy. A kappa coefficient value of 0.669 (p = 0.001), indicated a substantial level of agreement for the presence/absence of IDH between the pathologists. For the extent of IDH a kappa coefficient value of 0.6 (p = 0.038) indicated a moderate level of agreement. The pathologists agreed on the presence of IDH in 10 of the 27 cases. Subdural hemorrhage was recorded for 8 out of 27 cases. Of these 8 cases, it was agreed that 4 had IDH. Using standardized methods of image capture and assessment, inter-observer agreement for the presence/absence of IDH was substantial. In this paper, we report a much lower frequency of macroscopic IDH occurring alongside SDH than previous studies, which included both gross observation of IDH and histological examination.
Topics: Child, Preschool; Dura Mater; Female; Forensic Pathology; Hematoma, Subdural; Humans; Infant; Infant, Newborn; Intracranial Hemorrhages; Male; Observer Variation; Photography; Retrospective Studies
PubMed: 30915608
DOI: 10.1007/s12024-019-00103-8 -
Fa Yi Xue Za Zhi Jun 2018Due to the concealment and incidence higher than reported statistics, infanticide should attract the attention of legal medical experts. The infanticide process has... (Review)
Review
Due to the concealment and incidence higher than reported statistics, infanticide should attract the attention of legal medical experts. The infanticide process has common behavioral characteristics. The perpetrators are most frequently biological mothers who are unmarried, with inferior education, and lack of routine pregnancy tests. Medicolegal identification of infanticide cases includes identification of live births and causes of death. Besides the classical lung floating test, there are other methods to identify live births such as pulmonary interstitial emphysema, CT imaging examination, immunohistochemical examination of umbilical cord vitality markers. Neonatal line measurement is the only way to identify live births in corpse with severe decomposition. The main causes of death in infanticide are mechanic asphyxia and fatal head trauma. Shaken baby syndrome, as a common abusive head trauma, is pathologically characterized by the triad of encephalopathy, subdural haemorrhage (SDH) and retinal haemorrhage (RH). During the autopsy of suspected shaking baby syndrome, in addition to carefully examining cervical cord, the possibility of pathological temporal lobe hemorrhage should also be ruled out.
Topics: Craniocerebral Trauma; Forensic Medicine; Hematoma, Subdural; Humans; Infant; Infanticide; Retinal Hemorrhage; Shaken Baby Syndrome
PubMed: 30896108
DOI: 10.12116/j.issn.1004-5619.2018.06.018 -
The Neuroradiology Journal Feb 2022For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse...
For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.
Topics: Child Abuse; Hematoma, Subdural; Humans; Infant; Intracranial Thrombosis; Retinal Hemorrhage; Venous Thrombosis
PubMed: 34167377
DOI: 10.1177/19714009211026904 -
Neurology India 2022Malignant atrophic papulosis (MAP), or systemic Degos disease, is an obliterative vasculopathy of unknown origin, characterized by erythematous papules found on the... (Review)
Review
Malignant atrophic papulosis (MAP), or systemic Degos disease, is an obliterative vasculopathy of unknown origin, characterized by erythematous papules found on the skin, central nervous system (Neuro-MAP) and gastrointestinal tract. Neurological involvement occurs in approximately 20% of systemic cases, is progressive and largely fatal. It can be described in two forms: 1) the parenchymal presenting with meningoencephalitis and meningomyelitis and 2) the neurovascular presenting with large cerebral infarcts, intracranial and subarachnoid hemorrhage, subdural hematoma and venous sinus thrombosis. Predilection to subdural hematoma or hygroma is characteristic for neurological involvement in MAP in comparison to other vasculpathies and vasculitides. Peripheral nervous system manifestations are less common and include polyradiculopathy, neuropathy, and myopathy. CSF analysis usually shows mild to moderate pleocytosis, increased protein content, and normal glucose. Brain MRI may reveal cortical, subcortical and deep white matter ischemic lesions with possible nodular, leptomeningeal, dural, or ependymal enhancement. Spinal cord MRI may reveal patchy lesions from the periphery to the center or cord atrophy in progressive course. Neurological involvement in MAP has a grave prognosis. The interval from onset of papulosis to death averages two years in patients with neurological involvement. There is no confirmed treatment for MAP but there are promising reports with eculizumab and treprostinil.
Topics: Atrophy; Hematoma, Subdural; Humans; Malignant Atrophic Papulosis; Prognosis; Skin
PubMed: 35263846
DOI: 10.4103/0028-3886.338719 -
Journal of Medicine and Life 2015A developed society is usually also characterized by an elderly population, which has a continuous percentage growth. This population frequently presents a cumulus of... (Review)
Review
UNLABELLED
A developed society is usually also characterized by an elderly population, which has a continuous percentage growth. This population frequently presents a cumulus of medical pathologies. With the development of the medication and surgical treatment of different affections, the life span has increased and the pathology of an old patient has diversified as far as the cumulus of various pathological diseases in the same person is concerned. Chronic subdural pathologies represent an affection frequently met in neurosurgery practice. Any neurosurgeon, neurologist and not only, has to be aware of the possibility of the existence of a chronic subdural haematoma, especially when the patient is old and is subjected to an anticoagulant or antiaggregant treatment, these 2 causes being by far the etiological factors most frequently met in chronic subdural haematomas. With an adequate diagnosis and treatment, usually surgical, the prognosis is favorable. Although the surgical treatment presents a categorical indication in most of the cases, the fact that there are many surgical techniques, a great relapse rate, as well as the numerous studies, which try to highlight the efficiency of a technique as compared to another, demonstrate that the treatment of these haematomas is far from reaching a consensus among the neurosurgeons. The latest conservatory treatment directions are still being studied and need many years to be confirmed.
ABBREVIATIONS
CT = computerized tomography, MRI = magnetic resonance imaging.
Topics: Hematoma, Subdural, Chronic; Humans; Magnetic Resonance Imaging; Tomography, X-Ray Computed
PubMed: 26351527
DOI: No ID Found