Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Alexander M. McKinney, Linda R. Thompson, Charles L. Truwit, Scott Velders, Ayse Tuba Kendi, Andrew Kiragu

Research output: Contribution to journalArticle

28 Citations (Scopus)

Abstract

Background: Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective: To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods: IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results: In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4-7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion: HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/ hyperextension or from direct strangulation.

Original languageEnglish (US)
Pages (from-to)164-174
Number of pages11
JournalPediatric Radiology
Volume38
Issue number2
DOIs
StatePublished - Feb 1 2008
Externally publishedYes

Fingerprint

Brain Hypoxia-Ischemia
Craniocerebral Trauma
Blood Vessels
Dissection
Wounds and Injuries
Brain Stem
Angiography
Skull Fractures
Subdural Hematoma
Research Ethics Committees

Keywords

  • Abusive head trauma
  • Children
  • Diffusion
  • Hypoxic-ischemic encephalopathy
  • MRI

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Radiology Nuclear Medicine and imaging

Cite this

Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury. / McKinney, Alexander M.; Thompson, Linda R.; Truwit, Charles L.; Velders, Scott; Tuba Kendi, Ayse; Kiragu, Andrew.

In: Pediatric Radiology, Vol. 38, No. 2, 01.02.2008, p. 164-174.

Research output: Contribution to journalArticle

McKinney, Alexander M. ; Thompson, Linda R. ; Truwit, Charles L. ; Velders, Scott ; Tuba Kendi, Ayse ; Kiragu, Andrew. / Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury. In: Pediatric Radiology. 2008 ; Vol. 38, No. 2. pp. 164-174.
@article{135ec741188e4f77aa9333807686d0f3,
title = "Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury",
abstract = "Background: Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective: To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods: IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results: In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4-7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion: HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/ hyperextension or from direct strangulation.",
keywords = "Abusive head trauma, Children, Diffusion, Hypoxic-ischemic encephalopathy, MRI",
author = "McKinney, {Alexander M.} and Thompson, {Linda R.} and Truwit, {Charles L.} and Scott Velders and {Tuba Kendi}, Ayse and Andrew Kiragu",
year = "2008",
month = "2",
day = "1",
doi = "10.1007/s00247-007-0673-0",
language = "English (US)",
volume = "38",
pages = "164--174",
journal = "Pediatric Radiology",
issn = "0301-0449",
publisher = "Springer Verlag",
number = "2",

}

TY - JOUR

T1 - Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

AU - McKinney, Alexander M.

AU - Thompson, Linda R.

AU - Truwit, Charles L.

AU - Velders, Scott

AU - Tuba Kendi, Ayse

AU - Kiragu, Andrew

PY - 2008/2/1

Y1 - 2008/2/1

N2 - Background: Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective: To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods: IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results: In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4-7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion: HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/ hyperextension or from direct strangulation.

AB - Background: Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective: To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods: IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results: In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4-7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion: HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/ hyperextension or from direct strangulation.

KW - Abusive head trauma

KW - Children

KW - Diffusion

KW - Hypoxic-ischemic encephalopathy

KW - MRI

UR - http://www.scopus.com/inward/record.url?scp=38049069835&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=38049069835&partnerID=8YFLogxK

U2 - 10.1007/s00247-007-0673-0

DO - 10.1007/s00247-007-0673-0

M3 - Article

C2 - 18026946

AN - SCOPUS:38049069835

VL - 38

SP - 164

EP - 174

JO - Pediatric Radiology

JF - Pediatric Radiology

SN - 0301-0449

IS - 2

ER -