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