Neuroradiological Findings in Non- Accidental Trauma Educational Pictorial Review

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1 Neuroradiological Findings in Non- Accidental Trauma Educational Pictorial Review M B Moss, MD; L Lanier, MD; R Slater; C L Sistrom, MD; R G Quisling, MD; I M Schmalfuss, MD; and D Rajderkar, MD Contact: Rajdda@radiology.ufl.edu College of Medicine - University of Florida, Gainesville, FL, United States. Disclaimer: We do not have any conflict of interest or financial gain to disclose

2 Outline 1. Simulation-SIM as assessment tool 2. Clinical and Neuroradiolgical findings of Non- Accidental Trauma (NAT) 3. Pitfalls Congenital infections Birth related injuries e.g. subdural tentorial hematomas 4. Search pattern to prevent observational errors 5. Assertive guidelines to call NAT to avoid cognitive errors 6. Recommended imaging plan for a follow up

3 Background Computer aided simulation (SIM) was developed and designed to test residents for readiness for call 8 hour simulation of 65 emergent & critical care cases of varying degrees of difficulty, including normal studies using full DICOM image sets SIM was taken by 127 first (R1) & second (R2) year residents from 16 USA radiology training programs

Results 75% of the residents either called the study normal (observational error) or gave an incorrect diagnosis (cognitive error) No significant difference between R1 and R2

4 Results 75% of the residents either called the study normal (observational error) or gave an incorrect diagnosis (cognitive error) No significant difference between R1 and R2 residents with an average scores of 17 versus 25% respectively Conclusion: Significant observational and cognitive gap exists in detecting and differentiating NAT from other disease entities

5 Brain: Axial loading injury - Skull fracture High impact trauma - Skull base fracture & brain injury Penetrating trauma Shaking Injury - Diffuse axonal injury & SDH Shearing injury Venous tethering Asphyxiation/Hypoxic brain injury Long term sequelae - Global atrophy Spine Neuro NAT Manifestations Axial loading injury - Vertebral compression fracture Spinal cord injury

$arrows) with associated skull fracture$ $rib fractures (yellow arrows), better$

6 1 2 SIM Case % of the residents failed to make the diagnosis indicating the need to revisit the radiology of NAT Fig 1 - Extensive scalp hematoma (white arrows) with associated skull fracture (red arrows) Fig 2 - Right sided posterior rib fractures (yellow arrows), better identified on zooming (Fig 3) and changing windows (Fig 4)

Repetitive shaking leads to mixed age of extra-axial blood products (white arrows).

7 Traditional Radiology Teaching of Neuro NAT Prominent extra-axial spaces (between purple arrows) predispose for extra-axial bleeding after getting shaken. Repetitive shaking leads to mixed age of extra-axial blood products (white arrows). Larger subdural hemorrhage (SDH) (white arrows) is an uncommon spontaneous event in infants. Other types of blood collections include: subpial (yellow arrow) & intradural (pink arrow) hemorrhage and subdural hygromas (purple arrows)

$fracture (red arrows) 1 Traditional$ $Typical transverse fracture of the$ temporal bone (red arrows) 3 4 Axial

$fracture (pink arrow) with its$

8 Fig 1 & 2 - Axial loaded skull fracture (red arrows) 1 Traditional Radiology Teaching of Neuro NAT 2 Typical transverse fracture of the temporal bone (red arrows) 3 4 Axial CT (Fig 3) shows transverse oriented fracture (pink arrow) with its complete extent better demonstrated with on the 3D reformation (Fig 4)

9 A complete review of the additional findings in NAT Cervical Spine/Cord Injury Most commonly from a shaking/ whiplash type mechanism May damage the lower brainstem and upper cervical cord Could present as apnea and hypoxia. Subdural and epidural cord hematomas, cord contusion and ligamentous rupture Cervical spine MRI must be performed if there is any clinical suspicion of shaking-type injury

Spinal Trauma Long segment spinal cord edema Axial loaded associated

reveal spinal cord edema extending from the foramen magnum to C7 level

deformity of a vertebral body (white arrow) Teaching point: Cervical

10 Spinal Trauma Long segment spinal cord edema Axial loaded associated spinal column injury 1 2 Sagittal (Fig 1) & axial (Fig 2) T2 images reveal spinal cord edema extending from the foramen magnum to C7 level (red arrows) Lateral lumbar spine X-ray shows typical compression deformity of a vertebral body (white arrow) Teaching point: Cervical spine CT without bony injury is clearly underestimates the extent of cord injury

11 Shaking Injury Diffuse Axonal Injury preferentially affects Gray-white matter junctions Corpus callosum & basal ganglia Dorsolateral aspect of the pons & upper brainstem Shearing Injury causes Disruption of delicate cortical bridging veins as they leave the cortex to enter the dural venous sinuses, most commonly the superior sagittal sinus Subdural hematomas & hygromas

DWI Multiple areas of restricted diffusion along the

temporal lobe, right temporal pole, anterior frontal

plate (red arrows) Teaching Point: Diffuse axonal

often affects the gray-white matter junction, the

12 DWI Multiple areas of restricted diffusion along the right tentorial incisura, in the mesial right temporal lobe, right temporal pole, anterior frontal lobes bilaterally and adjacent to the cribriform plate (red arrows) Teaching Point: Diffuse axonal injury from shaking is usually multifocal and most often affects the gray-white matter junction, the corpus callosum, basal ganglia and the dorsolateral pons & upper brainstem

P1 Perforator (Shear) Injury DAI in a 2-Month-Old with

is often subtle requiring special attention to SWI and DWI

not a post herniation effect (yellow arrow) Figs 1 & 2 show a

convexity and a left frontal acute SDH (red arrows) with foci

13 P1 Perforator (Shear) Injury DAI in a 2-Month-Old with History of SDH Teaching Point: Diffuse axonal injury is often subtle requiring special attention to SWI and DWI sequences P1 perforator distribution edema: a shear effect not a post herniation effect (yellow arrow) Figs 1 & 2 show a focus of microhemorrhage (white arrow) in the right frontal convexity and a left frontal acute SDH (red arrows) with foci of acute restriction in the left frontal lobe (yellow arrows) in Fig 3 &4

3-Month-Old with Seizures and Periorbital Bruising 1 2 3 4 Figs 1

veins (orange arrows) separating the subdural hygroma (pink

3 & 4) reveal extensive subdural enhancement with pial irritation

arrows) Teaching Point: Patients with diffuse atrophy from

14 3-Month-Old with Seizures and Periorbital Bruising Figs 1 & 2 show dilated subarachnoid spaces (red arrows) with bridging veins (orange arrows) separating the subdural hygroma (pink arrow) from diffuse brain atrophy Post-contrasted T1 images (Figs 3 & 4) reveal extensive subdural enhancement with pial irritation suggestive of mixed age subdural & subarachnoid hemorrhage (white arrows) Teaching Point: Patients with diffuse atrophy from repetitive trauma may require contrast to differential acute from chronic injury

15 Hypoxic Ischemic Injury & Strangulation Asphyxiation/Hypoxic brain injury Strangulation Smothering Apnea associated w/ brain stem stretch injuries in infants Affects Whole brain if severe High ATP utilization zones if less severe

16 Hypoxic Ischemic Injury & Strangulation Hypoxic ischemic injury (HIE) Spares the basal ganglia, thalami brainstem and cerebellum Strangulation May affect unilateral watershed territory due to extrinsic compression of carotid artery Hemorrhagic laminar necrosis may occur 7-10 days after initial insult Must perform MRA to assess for vascular injury

10 Month Old with Seizures 1 2 3 Fig 1shows bilateral, frontal

focal areas of diffusion restriction in the subcortical white

Figs 2 & 3) Teaching Point: Strangulation often presents

17 10 Month Old with Seizures Fig 1shows bilateral, frontal SDH (red arrows) with parafalcine extension (white arrow) and focal areas of diffusion restriction in the subcortical white matter in the right MCA/ACA watershed zone (yellow arrows in Figs 2 & 3) Teaching Point: Strangulation often presents unilaterally and should trigger MRA of the neck to assess for vascular injury

18 Diffuse Brain Swelling (Dysautoregulation vs Hypoxia) 1 2 Initial CT scan (Fig 1) read as Normal. Follow up CT 24 hours later (Fig 2) reveals loss of grey white matter differentiation, diffuse hypodensity of the white matter and complete effacement of the sulci consistent with diffuse cerebral edema. Teaching Point: Causes of diffuse cerebral swelling include Diffuse primary injury (e.g. DAI) and metabolic derangement

11-Month-Old with Trauma 1 2 3 Figs 1&2 show a large subgaleal

arrow) due to diffuse edema causing effacement of the prepontine

Teaching Point: Serial imaging & comparisons to priors, if

19 11-Month-Old with Trauma Figs 1&2 show a large subgaleal hematoma (orange arrow) & upward transtentorial herniation (red arrow) due to diffuse edema causing effacement of the prepontine cisterns (yellow arrow) and diffuse sulcal effacement (pink arrows) Teaching Point: Serial imaging & comparisons to priors, if available, are critical for identification of early signs of diffuse edema / brain injury

$Direct Impact Trauma High likelihood of skull fracture, best seen on 3D reconstruction Cortical contusion Focal parenchymal contusions &$

20 Direct Impact Trauma High likelihood of skull fracture, best seen on 3D reconstruction Cortical contusion Focal parenchymal contusions & lacerations near scalp hematoma or fracture Traumatic SDH & subarachnoid hemorrhage tend to stem from direct disruption of vessels at fracture site

$no overt skull fractures or soft tissue$

21 Unresponsive & Apneic Child Initial CT Axial, non-contrasted CT images reveal diffuse interhemispheric and tentorial SDH (red arrows) and developing subdural hygromas (yellow arrows) with no overt skull fractures or soft tissue hematoma

1 Unresponsive & Apneic Child 2 3 4 Follow

enlargement of the panhemispheric subdural

22 1 Unresponsive & Apneic Child Follow up MRI T1 (Fig 1 & 3) and FLAIR (Fig 2) show acute SDH (red arrows) superior to the transverse sinuses with significant enlargement of the panhemispheric subdural fluid collections (yellow arrows), as compared to the initial CT with minimal blood foci on T2* gradient imaging (white arrows in Fig 4)

23 Stabbing/Penetrating Trauma Similar potential findings as direct impact trauma Other complications include Intracerebral hematoma Posttraumatic aneurysm Carotid-cavernous fistula Arterial occlusion or venous thrombosis CSF leakage CT is recommended due to possible retained metallic foreign bodies

30-Day-Old with Trauma 1 2 3 Coronal (Fig 1) and axial (Figs 2 & 3) CT images show

stasis and acute SDH & subarachnoid hemorrhage along the vertex.

effacement of the ventricles and sulci Teaching Point: Even when imaging clearly shows

24 30-Day-Old with Trauma Coronal (Fig 1) and axial (Figs 2 & 3) CT images show hyperdensities in the subarachnoid spaces (red arrows) likely related to subcortical venous stasis and acute SDH & subarachnoid hemorrhage along the vertex. This is associated with diffuse loss of gray-white differentiation (yellow arrows) & effacement of the ventricles and sulci Teaching Point: Even when imaging clearly shows diffuse cerebral edema & HIE with its poor prognosis complete documentation of findings (e.g. fractures) is still needed for medical legal purposes.

3-Month-Old with Right Parietal Trauma 1 2 3 Initial CT Fig 1shows

$displaced right parietal bone fracture (yellow arrows in Fig 2) and a$ This wedge-shaped defect in the pariental lobe in association with high

25 3-Month-Old with Right Parietal Trauma Initial CT Fig 1shows extensive right facial & scalp hematoma (red arrows) with comminuted and displaced right parietal bone fracture (yellow arrows in Fig 2) and a small subjacent hemorrhagic contusion and edema (white arrow in Fig 3). This wedge-shaped defect in the pariental lobe in association with high energy impact is concerning for entrapped brain tissue in the adjacent fracture fragments.

3-Month-Old with Right Parietal Trauma MRI follow up 3

wedge-shaped defect extending from the right parietal

$a focus of entrapped brain tissue at the fracture site$ arrow) on the T2* gradient sequence Teaching Point: High

26 3-Month-Old with Right Parietal Trauma MRI follow up 3 days later T1 and DWI images confirm the posttraumatic wedge-shaped defect extending from the right parietal cortex to the right ventricular trigone (red arrows) with a focus of entrapped brain tissue at the fracture site (yellow arrow) and small volume extra axial blood (white arrow) on the T2* gradient sequence Teaching Point: High velocity direct impact trauma tends to have a more focal distribution

27 Vertex tethering / laceration Linear blood in subcortical location on CT is consistent with brain laceration (red arrow) Widespread cortical & subcortical brain lacerations (yellow arrows) on DWI

31 Month-Old Boy after Fall 1 2 3 4 Initial CT

$occipital bone fracture extending into the$ Fig 2 shows a small right cerebellar

28 31 Month-Old Boy after Fall Initial CT Fig 1 & 3 reveal a slightly depressed occipital bone fracture extending into the right temporal bone (red arrows). Fig 2 shows a small right cerebellar hemorrhage (yellow arrows) and a possible infarct (pink arrow). Fig 4 demonstrates right parietal occipital brain laceration (white arrow) subjacent to the skull fracture.

31 Month-Old Boy after Fall 1 2 3 Follow up MRI Fig 1 & 2 illustrate increased conspicuity of the brain

29 31 Month-Old Boy after Fall Follow up MRI Fig 1 & 2 illustrate increased conspicuity of the brain laceration (red arrows) with a new focus of diffusion restriction in the anterior temporal pole (yellow arrow). Fig 3 reveals more extensive right cerebellar hemorrhage (pink arrow) than indicated on the initial CT Teaching Point: CT may underestimate the extent of hemorrhage, as well as more subtle injuries away from the impact site

macrocephaly related to chronic subdural effusions (red arrows) producing an

30 Long-Term Sequelae Metabolic insults lead to global atrophy, most commonly following diffuse cerebral edema (if the patient survives) Unexplained macrocephaly related to chronic subdural effusions (red arrows) producing an increased cranial volume Unexplained atrophy (pink arrows) & acute parafalcine SDH (yellow arrows)

1 2 Axial CT post NAT(Fig 1 & 2) shows decreased basal ganglia

arrow) Initial DWI Brain stem injury apparent at 10 days follow up

diffusion (red arrows) with subtle involvement of the pons (yellow

31 1 2 Axial CT post NAT(Fig 1 & 2) shows decreased basal ganglia density (red arrows) & sulcal effacement (yellow arrows) related to hypoxic effects (confirmed at autopsy). In addition, there is a focal acute cortical hemorrhage (orange arrow) Initial DWI Brain stem injury apparent at 10 days follow up MR Initial DWI sequence shows few scattered foci of restricted diffusion (red arrows) with subtle involvement of the pons (yellow arrows) that becomes markedly more apparent on the follow up DWI 10 days later Alive at this time Dying at this time

Pitfalls in the diagnosis of NAT: Patient 1

(red arrows) consistent with DAI in this

seen on a MRI done for postnatal HIE in this

32 Patient 1-HSV Infection Simulating NAT Patient 2- Birth Related SDH Simulating NAT Pitfalls in the diagnosis of NAT: Patient 1 - Mutlifocal areas of diffusion restriction (red arrows) consistent with DAI in this patient with suspicion for NAT that were proven to be caused HSV infection. Patient 2 Tentorial SDH (yellow arrows) was seen on a MRI done for postnatal HIE in this premature infant which should not be interpreted as NAT on follow up MRI

Importance of Follow up: Fatal sequelae of NAT 1 2

required n unresponsive patients in whom the

subdural catheter in the left parietal region in

CT done 2 days later (Figs 2-4) reveal a large

herniation (orange arrow) Non contrast CT

33 Importance of Follow up: Fatal sequelae of NAT Teaching Point: Routine follow up CTs are required n unresponsive patients in whom the clinical signs and symptoms are unreliable to detect the fatal complications. 5 6 Initial non contrast CT (Fig 1) shows a subdural catheter in the left parietal region in this unresponsive patient with known NAT. CT done 2 days later (Figs 2-4) reveal a large left MCA infarct (yellow arrows) with uncal herniation (orange arrow) Non contrast CT performed 9 days after the initial CT (Fig 5 & 6) shows hemorrhagic transformation of the left MCA infarct (white arrows).

Proposed Imaging Protocol by Jaspan et al.

normal/equivocal CT Days 3-4 MRI: T1, T2, FLAIR and

34 Proposed Imaging Protocol by Jaspan et al. Suspected NAT CT Day 0 Days 1-2 Continued follow-up, as indicated Skull radiographs and Cranial US CT If neurologic symptoms & normal/equivocal CT Days 3-4 MRI: T1, T2, FLAIR and DWI T2*GRE or SWI Suspected Vascular Injury MRA At 10 days If intracranial abnormalities

35 Conclusions Traditional outlook for NAT in Neuroradiology Subdural collections in different stages Multiple fractures of skull; Mutiple Wormian bones/sutural diastases; Classic transverse fracture of the temporal bone Additional findings which all the Neuroradiologists need to look for are- Axial loading injury and spinal cord injury in spine In brain a range of injury pattern- DAI,Shearing injury, hypoxic injury, P1 perforator injury, delayed manifestations like large arterial territorial stroke, venous tethering and laceration

36 References Bradford, R., et al(2013). Serial neuroimaging in infants with abusive head trauma: Timing abusive injuries - Clinical article. Journal of Neurosurgery: Pediatrics. Dwek, J. R. (2011). The radiographic approach to child abuse. Clinical Orthopaedics and Related Research. Fernando, S., et al (2008). Neuroimaging of nonaccidental head trauma: Pitfalls and controversies. Pediatric Radiology. Foerster, B.R. et al. Neuroimaging Evaluation of Non-Accidental Head Trauma with Correlation to Clinical Outcomes: A Review of 57 Cases. The Journal of pediatrics (2009). Hsieh, K. L.-C., et al (2015). Revisiting neuroimaging of abusive head trauma in infants and young children. AJR. Kemp, A. M., et al (2011). Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Archives of Disease in Childhood. Tung, G., et al (2006). Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics. Lonergan, G. J., et al( 2003). From the Archives of the AFIP. Child Abuse: Radiologic-Pathologic Correlation RadioGraphics. Piteau, S. J., et all(2012). Clinical and Radiographic Characteristics Associated With Abusive and Nonabusive Head Trauma: A Systematic Review. Pediatrics.

NEURO IMAGING 2. Dr. Said Huwaijah Chairman of radiology Dep, Damascus Univercity

NEURO IMAGING 2. Dr. Said Huwaijah Chairman of radiology Dep, Damascus Univercity NEURO IMAGING 2 Dr. Said Huwaijah Chairman of radiology Dep, Damascus Univercity I. EPIDURAL HEMATOMA (EDH) LOCATION Seventy to seventy-five percent occur in temporoparietal region. CAUSE Most likely caused