Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces

Restricted access

OBJECTIVE

Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.

METHODS

The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.

RESULTS

Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.

CONCLUSIONS

The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.

ABBREVIATIONS AHT = abusive head trauma; BESS = benign enlargement of the subarachnoid spaces; CAP = Child Abuse Pediatrics; CSI = concomitant suspicious injury; SDH = subdural hematoma.

Article Information

Correspondence James Anderst, Department of Pediatrics, Children’s Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108. email: jdanderst@cmh.edu.

INCLUDE WHEN CITING Published online November 3, 2017; DOI: 10.3171/2017.7.PEDS17317.

Disclosures Dr. Anderst reports that he has served as a consultant to the prosecution and defense in cases of alleged child abuse.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Anderst JDCarpenter SLAbshire TC: Evaluation for bleeding disorders in suspected child abuse. Pediatrics 131:e1314e13222013

2

Christian CW: The evaluation of suspected child physical abuse. Pediatrics 135:e1337e13542015

3

Cooperman DRMerten DF: Skeletal manifestations of child abuseReece RMChristian CW (eds): Child Abuse Medical Diagnosis and Managemented 3. Elk Grove Village, IL: American Academy of Pediatrics2009121165

4

Gabaeff SC: Investigating the possibility and probability of perinatal subdural hematoma progressing to chronic subdural hematoma, with and without complications, in neonates, and its potential relationship to the misdiagnosis of abusive head trauma. Leg Med (Tokyo) 15:1771922013

5

Greiner MVRichards TJCare MMLeach JL: Prevalence of subdural collections in children with macrocrania. AJNR Am J Neuroradiol 34:237323782013

6

Gulino SP: Autopsy findingsFrasier LRauth-Farley KAlexander RParrish R (eds): . St. Louis: GW Medical Publishing2006297313

7

Hansen JBFrazier TMoffatt MZinkus TAnderst JD: Evaluation of the hypothesis that choking/ALTE may mimic abusive head trauma. Acad Pediatr 17:3623672017

8

Keenan HT: Epidemiology of abusive head traumaJenny C (ed): . St. Louis: Saunders Elsevier20113538

9

Kemp AMJaspan TGriffiths JStoodley NMann MKTempest V: Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child 96:110311122011

10

Kleinman PKRosenberg AETsai A: Skeletal trauma: general considerationsKleinman PK (ed): Diagnostic Imaging of Child Abuseed 3. Cambridge, UK: Cambridge University Press20152352

11

Levin AV: Retinal hemorrhages: advances in understanding. Pediatr Clin North Am 56:3333442009

12

Lindberg DMBeaty BJuarez-Colunga EWood JNRunyan DK: Testing for abuse in children with sentinel injuries. Pediatrics 136:8318382015

13

Looney CBSmith JKMerck LHWolfe HMChescheir NCHamer RM: Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology 242:5355412007

14

Maguire SMann M: Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates. Evid Based Child Health 8:2552632013

15

Maguire SPickerd NFarewell DMann MTempest VKemp AM: Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Arch Dis Child 94:8608672009

16

McKeag HChristian CWRubin DDaymont CPollock ANWood J: Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces. J Neurosurg Pediatr 11:4384442013

17

Miller DBarnes PMiller M: The significance of macrocephaly or enlarging head circumference in infants with the triad: further evidence of mimics of shaken baby syndrome. Am J Forensic Med Pathol 36:1111202015

18

Rooks VJEaton JPRuess LPetermann GWKeck-Wherley JPedersen RC: Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol 29:108210892008

19

Section on Radiology: Diagnostic imaging of child abuse. Pediatrics 123:143014352009

20

Sheets LKLeach MEKoszewski IJLessmeier AMNugent MSimpson P: Sentinel injuries in infants evaluated for child physical abuse. Pediatrics 131:7017072013

21

Squier WMack JGreen AAziz T: The pathophysiology of brain swelling associated with subdural hemorrhage: the role of the trigeminovascular system. Childs Nerv Syst 21:200520152012

22

Tucker JChoudhary AKPiatt J: Macrocephaly in infancy: benign enlargement of the subarachnoid spaces and subdural collections. J Neurosurg Pediatr 18:16202016

23

Vinchon MDelestret IDeFoort-Dhellemmes SDesurmont MNoulé N: Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature. Childs Nerv Syst 26:119512052010

24

Wood JNFeudtner CMedina SPLuan XLocalio RRubin DM: Variation in occult injury screening for children with suspected abuse in selected US children’s hospitals. Pediatrics 130:8538602012

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 60 60 52
Full Text Views 98 98 31
PDF Downloads 147 147 44
EPUB Downloads 0 0 0

PubMed

Google Scholar