ESR Essentials: imaging of suspected child abuse-practice recommendations by the European Society of Paediatric Radiology

Abstract

The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up. We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report. To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11-14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis. All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2-5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine. We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice. KEY POINTS: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected. A follow-up skeletal survey is mandatory 11-14 days after the initial survey. If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.

Keywords: Child; Clinical protocols; Diffuse axonal injury; Fractures (bone); Physical abuse.

Fig. 1

Spectrum of impact injuries. A 12-month-old baby boy presents with a boggy scalp swelling, with no explanation or history of trauma from their parents/carers. A, B axial CT scan on bone windows (A) and 3-D reconstruction (B), reveal a slightly displaced left parietal fracture (arrows) extending into the sagittal suture, accompanied by bilateral scalp swelling (arrowheads). C Axial unenhanced CT image on parenchymal windows shows an acute, hyperdense left parietal haemorrhagic contusion (arrow). D–F Axial T2-weighted (D), susceptibility-weighted (SWI) (E) and parametric apparent diffusion coefficient map (F) magnetic resonance images also demonstrate the contusion. Note areas of signal void (arrows) due to susceptibility artefact, more pronounced in the SWI image (E)

Fig. 2

Spectrum of AHT injuries. An 8-month-old baby boy presents in an unexplained floppy and unresponsive state. A Axial unenhanced CT scan on parenchymal windows reveals multiple subdural haemorrhagic collections, with mixed density (arrows), one of them being parafalcine (arrowhead). B–D Coronal fluid-attenuated inversion recovery (B), axial diffusion-weighted (DWI) (C), and axial parametric apparent diffusion coefficient map (D) magnetic resonance images (MRI) of the brain depict subdural collections (arrows) with torn, thrombosed bridging veins (arrowheads in B) and hypoxic-ischaemic injury of the right occipital region (arrow in C), manifesting with restricted diffusion (arrow in C, D). A susceptibility artefact in the right frontal area is due to an in situ intracranial pressure monitor (arrowhead in C). E, F Sagittal T2-weighted MRI of the spine reveals cervical spinal ligamentous injury (arrow in E) and a spinal SDH (arrow in F)

Fig. 3

Mimics of abusive craniospinal trauma. All patients shown are infants. A, B Axial unenhanced CT on parenchymal windows (A) and axial magnetic resonance parametric apparent diffusion coefficient map (B) images in an encephalopathic girl with factor VIII deficiency show multifocal SDHs (arrows). C, D Axial fluid-attenuated inversion recovery magnetic resonance images (MRI) in a boy with glutaric aciduria I, show a right subdural collection (arrow in C), widened opercula (arrows in D), and atrophy of the basal ganglia (arrowhead in D). E, F Axial unenhanced CT image on parenchymal windows (E) and susceptibility-weighted (F) MRI in a boy with pneumococcal sepsis show small subdural collections (arrows in E), and microhemorrhages (arrow in F). G, H Axial unenhanced CT scans on parenchymal windows in a boy (G) and girl (H) following accidental trauma show a hyperacute extradural haematoma (arrow in G) with a skull fracture and SDH (arrowhead in H), and subarachnoid haemorrhages (arrows in H). I, J Sagittal reformatted unenhanced CT is presented with a CT scan on parenchymal windows (I) and 3-D reconstruction (J) in a female neonate with osteogenesis imperfecta showing a birth-related subdural haematoma (arrow in I). The 3-D reconstruction displays sutural deformity presenting as a posterior parietal depression and multiple Wormian bones (arrow in J). K, L Sagittal T2-weighted (K) and axial T1-weighted (L) MRI of the spine in a girl with osteogenesis imperfecta illustrate multilevel vertebral body compression fractures (arrow in K), and a post-lumbar puncture spinal extra-axial collection (arrow in L)

Fig. 4

Fractures/presentations typical of inflicted injury. A Anteroposterior (AP) chest radiograph in a 9-month-old girl with no history of trauma, shows healing fractures of the posterior arcs of the right 6th–11th ribs (arrows). B AP radiograph of the left wrist in an 8-month-old boy shows classic metaphyseal fractures of the distal radius and ulna (circles). C AP radiograph of the left femur in a 5-week-old boy shows a displaced and angulated mid-shaft fracture. There is no subperiosteal new bone formation nor is there a callus, consistent with an acute fracture. There was no convincing history of trauma

Fig. 5

Skull fractures on 3-D reconstructed CT images. A, B Complex fractures (arrows) of the right parietal bone (A) with a displaced quadrangular-shaped fragment (asterisk in A) and linear fracture (arrows) of the left parietal bone (B) in a 6-week-old boy. C, D Complex fractures of the left (C) and right (D) parietal bones (arrows) in a 5-month-old boy

Fig. 6

Suspected child physical abuse investigative pathway. ^aIf the local multidisciplinary team is not able to reach a decision, referral to a specialist centre is recommended. ^bAdditional sites (e.g. hands/feet) may be imaged depending on findings on the initial survey. AHT, abusive head trauma; CTB, computed tomography brain; D, dimensional; MDT, multidisciplinary team; MRI, magnetic resonance imaging, T, tesla