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Neuroimaging in Abusive Head Trauma and Its Mimics

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Neuroimaging in Abusive Head Trauma and Its Mimics
Peter Kalina, MD, FACR, Mayo Clinic, Rochester MN

Objective: The evaluation of potential victims of pediatric non-accidental trauma and specifically abusive head trauma requires a multidisciplinary team effort. Responsibilities include recognizing new cases of NAT as well as safely excluding cases that mimic AHT. We sought to determine the incidence and type of head injuries encountered in children being evaluated for AHT as well as frequently encountered mimics that subsequently create so much controversy in the courtroom. This is a 4-year retrospective review of children evaluated for AHT by our institution's Family Advocacy Program, a multidisciplinary team including pediatricians, pediatric surgeons, neurosurgeons, neuroradiologists, social workers and law enforcement. Cases reviewed were submitted between 2011 and 2014, age younger than 12 months and availability of brain imaging. In the 48 months, 221 children were referred for evaluation for potential NAT (AHT and other). Of the 221, 107 (48 %) were age less than 12 months. Of the 107, 64 had brain imaging (60 %). The study included 64 children (age range 11 days to 11 months). Of the 64, 45 (70 %) had a positive brain imaging study. Of the 45, 10 (22 %) were determined to be the result of AHT. The remaining 35 were accidental head trauma or other. The most frequently noted findings in the cases deemed positive for AHT were the classic imaging triad of abusive head trauma: subdural hematoma, retinal hemorrhage, and encephalopathy. This triad is well known to those who care for AHT victims. In many cases that reach court, contentious exchanges arise between prosecution and defense experts. Controversies include: dating of subdural hematomas, mixed density subdurals, acute on chronic subdural versus re-bleed of pre-existing hemorrhage, alternative causes of “the triad,” overlapping findings between accidental and non-accidental trauma, possibility of “lucid interval” with subdurals, absence of neck injuries, possibility of similar injuries from short falls and, if shaking can actually result in such extensive injuries. Examples of positive cases as well as mimics will illustrate these controversies.
Objective: At the end of the presentation, the learner will be better able to differentiate brain imaging in cases of abusive head trauma from cases of accidental head trauma.Objective Content: Multiple cases of abusive head trauma will be compared to mimics to help the listener differentiate them in a clinical or courtroom setting.


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