Blood Brain And Bones

Evidence Based Update

Imaging In Non Accidental Injury And The Mimics

Patrick D. Barnes, MD
http://www.stanford.edu/~pbarnes/
pbarnes@stanford.edu

Can imaging distinguish between accidental or non accidental or from predisposing or complicating medical conditions? Can it discern bone fragility disorders? What is shaken baby syndrome and the battered child syndrome according to traditional literature? What is evidence based medicine and quality evidence? What are the Rules Of Evidence and the Standards For Admissibility For Expert Testimony? Do SDH rebleed? Can you have a lucid interval? Does birth ever cause a SDH? Do retinal hemorrhages occur only with SDH in non accidental injuries? What are the dural and retinal hemorrhage differential diagnosis’?

An evidenced based presentation involving shaken baby biomechanics of the brain.  Historical reviews of the theory from:

1) Caffey 1972 Whiplash Shaking

2) Guthkelch 1971 Infant SDH Whiplash Theroy

3) Ommaya 1968 Whiplash History

4) Duhaime et al 1987 SBS

5) Prange 2003 Falls, Shakes And Impacts

References for evidence based head injury in NAI neuropathology, acute life threatening event and the differential diagnosis for acute life threatening events.

Neuropathology + Biomechanical Evidence Base Conclusions:

• Shaking may theoretically cause brain injury if associated with
cervical spinal cord injury.

• Impact may produce direct or indirect brain injury (accidental or
NAI).

• Brain edema with thin SDH (dural vascular plexus origin) may
reflect Hypoxia-Ischemia + Cascade (accidental or NAI).

• Brain edema with thin SDH may result from medical causes (e.g.
Hypoxia-Ischemia + Cascade) from any cause of ALTE).

• Should always do both Brain and Cervical Spine CT, as well as
MRI.

• Imaging may not distinguish accidental from nonaccidental injury, or
from predisposing or complicating medical conditions.

• Significant head injury, including death, may result from low fall levels
(or any Impact, accidental or NAI).

• Such injury may be associated with a lucid interval (i.e. caretaker
blamed for delay).

• The lucid interval invalidates the premise that the last caretaker is
always responsible in alleged NAI.

• In other cases, the injury may result in immediate deterioration with
malignant edema & progression to death.

• Predispositions including Genetic?

• Imaging may not distinguish nonaccidental from accidental injury.

• Re-hemorrhage may occur in an old SDH without recent
trauma and be associated with a lucid interval (Sutures !!).

• SDH occurs in benign extracerebral collections.

• Old SDH may date back to Birth.

• Serial head circumference measurements, caregiver
education, preventive measures, attention to nonspecific
symptoms, early imaging “before the crash”.

• Imaging may not distinguish nonaccidental injury from
accidental injury.

Evidence Base Conclusions
• The Triad: RH + SDH + Edema not specific for NAI.
• May occur with accidental trauma.
• May occur with medical conditions.
• Must consider Predisposing Risk Factors.
• Must consider Multifactorial, Synergistic, & Cascade Effects.

Doctors corner:

-Vaccinations

-NAI Recommendations – A Compassionate Approach

- Madatory Reportings

- CT and MRI In Alleged NAI Limitations

- Timing of Hemorrhage

- Comparison Imaging Of SDH

- NAI Skeletal Fragility Disorders With Comparison Imaging

- Case Studies

Source:

http://www.stanford.edu/~pbarnes/docs/publications/UpdateBrainImagingNAI.pdf