Post on 10-Jun-2015
NEUROSURGICAL ASPECTS OF
CHILD ABUSE
Tarik Al-Sheikh, FRCS, FRCS (N.S)Department of Neurosurgery
Ibn Sina Hospital-Kuwait
• Child Abuse
=Non-accidental head injury (NAI)
=Inflected Injury
=Abusive injury
=Abusive head trauma (AHT)
=Shaken baby syndrome (SBS)
=Battered child syndrome
• Sensitive/ Difficult/ Controversial
• Stressful to clinician/ Legal issues +Medicine
• Unfamiliar/ Uncomfortable
• Deliberate or not?
• Catastrophic outcome life-long!!
• Little experience
• You don’t imagine/ expect it
Definition
• Children presenting
with a complex of
signs and symptoms
resulting from mis-
treatment by their
caretakers
• 1930’s-1940’s
• Kempe 1962
History
Infantile SDH+ Long bones # +
Retinal hemorrhage Caffey (1946-1974)
History (cont.)
Types:
Neglect 38%
Physical Abuse 30%
Multiple types 29%
Psychological 3%
Sexual <1%
Epidemiology
• Difficult!!
-Ascertainment
-Inclusion criteria
-Follow-up
Epidemiology (cont.)
24.6/ 100 000 children <1 yr /Year Scotland
100-200 cases/ Year Germany
˷ 50 000 SBS/ Year (600-1400 infants of SBS/ A&E/ Year)
USA
903 000 children-1300 deaths Worldwide (2001)
1/4065 AHT risk by 1 year
• <2 yrs + HI → 24% due to AHT
• Mortality 19-30% →40% < 1 year
• Perm. brain damage 30%
• Perm. mild effect 30%
Epidemiology (cont.)
Epidemiology (cont.)
•Kuwait (1987)
•W. Al-Ateeqi et al. (2002)
•1991-1998; 60640 records
•16 children- AHT (38%-5 cases)
•7 lost follow-up
•2 died
Profile/ Risk Factors
• Young Parents (20’s)
• Low S-E status
• Unstable household
• Single parents
• Premature infants
• Prolonged stay in NICU
• Infants<1 year
• Infant disability
• H/O abuse of the
caretaker
• Psychiatric history
• Drug abuse
• Urban> Rural
• Boys> Girls
• Autumn + Winter
• Fathers 37%
• Boyfriends 20.5%
• Female babysitters 17.3%
• Mothers 12.6%
Perpetrators
• Physical examination conflicting the caretaker story
• True story is missing!!
• Clinician works as police interrogator!!
• Story:
1. Trivial blunt trauma
(i.e. Short-height fall)
2. No H/O trauma
Clinical Presentation
Clinical Presentation (cont.)Diagnosis is missed in:•Young Infants•Caucasian•Presence of both parents•Insurance status•No apnea/ no seizures
Clinical Presentation (cont.)•Variable→ Severity•Poor feeding/ vomiting•Failure to thrive•Lethargy/ irritability•Hypothermia/ chills•Failure to smile/ verbalize•Increased sleeping•Seizures/abnormal movements•Resp. difficulty/ apnea•Bradycardia•Bulging fontanelle•Large head circumference•Coma•Cardiovascular collapse
Clinical Presentation (cont.)• Initial contact gives the best chance
for history!!
• In-depth specific questions:
What?
When?
Who?
How?
Where?
• Tailor evaluation/ management + anticipate potential delayed complications
Imaging
*X-ray: skull, long bones, chest, spines
*CT: brain, chest- REPEAT!
*Ultrasound: head, abdomen
*MRI: brain, spines- REPEAT!!
*Radioisotope bone scan
Diagnostic signs
• Acute SDH: thin, posterior interhemispheric.
• Brain hypodensity: focal/ patchy/ extensive
(1-2 days)
• Intracranial injury in the absence of
accidental trauma
• Acute SDH + healing skeletal fractures +
retinal hemorrhage (+ detachment)-only in
NAI!!
• Low-height fall → skull #; EDH
But never acute SDH, brain swelling, brain
hypodensity
Diagnostic signs (cont.)
• Penetrating
• Direct Impact
NAI
• Inertial (SBS)
Head Injury Mech.
Children fall repeatedly without head injury!!!:
- Large head
-Weak cervical muscles
-Wide SD space
-Deformable skull
→Torn/ stretched veins + axonal injury + stretched cranio-cervical junction (brain stem)
→ Bleeding
Ischemic events
Apnea/ hypoxia
Head Injury Mech. (cont)
+REPEATED FORCEFUL
INSULTS
Evaluation/ Management• ABC
• Glasgow Coma Scale (GCS)
• Prevent 2° brain insult: BP
O2
Na+
Seizures
Edema
• Evacuate acute SDH Aspiration
Burrhole
Craniotomy/ Craniectomy
DOCUMENT/ REPORT TO AUTHORITY
Evaluation/ Management (cont.)
TEAM WORK
• Pediatrician expert in child abuse
• Pediatric neurosurgeon
• Pediatric radiologist
• Ophthalmologist
• Child protection staff
• Bacterial/ viral infections
• Bleeding disorders
• Cerebral aneurysm
• Osteogenesis imperfecta
• Metabolic disorders
• Accidental injury
Differential Diagnosis
Medico-Legal
• Civil proceedings
• Criminal proceedings - Consistent
- Presumptive
- Suspicious
(indeterminate)
Prognosis• NAI is worse than accidental injuries
• Worse prognosis with apnea/ seizures/ brain hypodensity
• 30% Death
• Blindness
• Deafness
• Paralysis
• Mental retardation
• Seizures
• Develop. Delay
• Parkinson’s disease
• Memory/attention/speech/learning problems
1-Primary:
Teach all parents
2-Secondary:
Teach population at risk
3-Tertiary:
Teach families involved
Prevention
THANK YOU