Various Cranial and Orbital Imaging Findings in Pediatric Abusive and Non-abusive Head trauma, and Relation to Outcomes

Differentiating Abusive Head Trauma (AHT) from Non-abusive Head trauma (NAHT) has profound clinical prognostic and legal implications, as certain imaging findings can individually be more suggestive of NAHT, while others are more suggestive of AHT. This study was set out to evaluate for an association between the various imaging findings in AHT with outcome.

Over 7-years, 55 children (age 0-4 years’) with head trauma and magnetic resonance imaging (MRI) were included as either: abusive (n = 16), non-abusive (n = 35), or indeterminate (n = 4). Two pediatric neuroradiologists jointly reviewed the imaging. The frequency of imaging findings and their association with ≥6 months’ outcome were calculated.

Comparing abusive versus non-abusive head trauma, complex subdural hematoma was present in 81% (n = 13/16) and 29% (n = 10/35), hypoxic-ischemic injury in 44% (n = 7/16) and 6% (n = 2/35), and diffuse axonal injury in 12% (n = 2/16) and 26% (n = 9/35), respectively. Susceptibility-weighted imaging (SWI) retinal hemorrhages were absent in non-abusive trauma (0/35), but present in 44% (n = 7/16) of the abusive group. In abuse, simple subdural hematomas were absent. Significant associations were found between the presence of abusive trauma with both hypoxic ischemic insult (OR = 12.83, p = 0.0024) and complex subdural hematoma (OR = 10.83, p = 0.0007). The presence of hypoxic ischemic injury (HII) did correlate significantly with clinical outcome (p = 0.017), while retinal hemorrhages on SWI and complex subdural hematoma did not (p = 0.1696-p = 0.2496).

Neuroimaging findings can be helpful in discriminating these two conditions on presentation, as well as in helping solidify the suspicion of AHT. Regarding eventual outcome in AHT, the most important predictor is clearly HII.