PDF icon Download PDF
Radiologie up2date 2011; 11(4): 315-333
DOI: 10.1055/s-0030-1256877
Pädiatrische Radiologie

© Georg Thieme Verlag KG Stuttgart · New York

Kindesmisshandlung: Nicht akzidentelle Kopfverletzungen

Child abuse: non-accidental head injuryD.  Klee, J.  Schaper
Further Information

Publication History

Publication Date:
16 December 2011 (online)

Also available ateRef
   Permissions and Reprints All articles of this category
Preview

Zusammenfassung

Die Kenntnis der Verletzungsmuster bei Kindesmisshandlung schützt das Kind vor einer weiteren Misshandlung und damit vor weiteren auch lebensbedrohlichen Schädigungen der körperlichen Integrität.

Neben den klinischen Aspekten müssen durch den Radiologen typische Verletzungsmuster des Skelettsystems, der Organe und der intrakraniellen Strukturen erkannt und wenn möglich zeitlich eingeordnet werden.

Die durchzuführenden diagnostischen Maßnahmen erfolgen nach festgelegten Leitlinien und die Beurteilung muss verschiedene Kriterien berücksichtigen. Diese werden in diesem Artikel dargestellt.

Die Diagnose einer Kindesmisshandlung sollte im Zweifelsfall verifiziert werden, indem ein bei Kindesmisshandlungen erfahrener Radiologe/Kinderradiologe die Bilder zweitbefundet.

Abstract

Knowledge of the radiological appearances that are the result of child abuse is an integral part of prevention of further, potentially life-threatening, injury. Radiologists must have un understanding of typical injury patterns of the skeletal system, visceral and intra-cranial structures, which should ideally be ordered chronologically. Necessary radiological investigations follow guidelines with specific criteria that are pointed out in this review. In equivocal cases of abuse, the opinion of a second (paediatric) radiologist should be sought.

Keywords

Non accidentell head injury - NAHI - child abuse

Kernaussagen

  • Bei der Kindesmisshandlung haben körperliche Gewalt und dabei insbesondere die nicht akzidentellen Kopfverletzungen (non-accidental head injury [NAHI]) eine große Bedeutung. Bei den NAHI kommen Frakturen, extraaxiale Blutungen und Parenchymverletzungen vor. Die Schädigungen können tödlich sein.

  • Neben den klinischen Aspekten müssen durch den Radiologen typische Verletzungsmuster des Skelettsystems, der Organe und der intrakraniellen Strukturen erkannt und wenn möglich zeitlich eingeordnet werden.

  • Einzeln stehende, bildmorphologisch absolut eindeutige Kriterien, die eine NAHI beweisen, d. h. von einer akzidentellen Kopfverletzung abgrenzen, gibt es nicht. Die Diagnose der NAHI ergibt sich aus der Befundkonstellation.

  • Beim Verdacht auf eine Kindesmisshandlung ist eine Bildgebung des Kopfes bei Kindern < 2 Jahren immer indiziert, da geringe zerebrale Verletzungen bei misshandelten Kindern nicht immer neurologisch offensichtlich sind. Die einzelnen Modalitäten für die Kopfuntersuchung sind in Abhängigkeit vom Alter und der klinischen Symptomatik durchzuführen.

  • Alter und Lokalisation einer intrakraniellen Verletzung sind wichtige Kriterien, die in die radiologische Beurteilung mit aufgenommen werden müssen. Wichtig ist auch noch die Beantwortung der Frage, ob es sich um ein einzeitiges oder mehrzeitiges Ereignis handelt.

  • Im Zweifellsfall und in Abhängigkeit von den lokalen Gegebenheiten sollte der Radiologe einen Kinderradiologen oder einen anderen in diesem Thema versierten radiologischen Kollegen konsiliarisch hinzuziehen.

Literatur

  • 1 Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma.  Am J Roentgenol Radium Ther. 1946;  56(2) 163-173 PubMed PMID: 20995763
    Search in Google Scholar
  • 2 Kempe C H, Silverman F N, Steele B F et al. The battered-child syndrome.  JAMA. 1962;  181 17-24 PubMed PMID: 14455086
    Search in Google Scholar
  • 3 Guthkelch A N. Infantile subdural haematoma and its relationship to whiplash injuries.  Br Med J. 1971;  2(5759) 430-431 PubMed PMID: 5 576 003, PubMed Central PMCID: PMC1796151
    Search in Google Scholar
  • 4 Kleinman P K. Shaken babies.  Lancet. 1998;  352(9130) 815-816 PubMed PMID: 9737307
    Search in Google Scholar
  • 5 Kleinman P K. Problems in the diagnosis of metaphyseal fractures.  Pediatr Radiol. 2008;  38(Suppl 3) 388-394 Review, PubMed PMID: 18470447
    Search in Google Scholar
  • 6 Lonergan G J, Baker A M, Morey M K, Boos S C. From the archives of the AFIP. Child abuse: radiologic-pathologic correlation.  Radiographics. 2003;  23(4) 811-845 Review, PubMed PMID: 12853657
    Search in Google Scholar
  • 7 Jayawant S, Rawlinson A, Gibbon F et al. Subdural haemorrhages in infants: population based study.  BMJ. 1998;  317(7172) 1558-1561 PubMed PMID: 9 836 654, PubMed Central PMCID: PMC28734
    Search in Google Scholar
  • 8 Haviland J, Russell R I. Outcome after severe non-accidental head injury.  Arch Dis Child. 1997;  77(6) 504-507 PubMed PMID: 9 496 184, PubMed Central PMCID: PMC1717403
    Search in Google Scholar
  • 9 Billmire M E, Myers P A. Serious head injury in infants: accident or abuse?.  Pediatrics. 1985;  75(2) 340-342 PubMed PMID: 3969337
    Search in Google Scholar
  • 10 King W J, MacKay M, Sirnick A Canadian Shaken Baby Study Group ,. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases.  CMAJ. 2003;  168(2) 155-159 PubMed PMID: 12 538 542, PubMed Central PMCID: PMC140423
    Search in Google Scholar
  • 11 King J, Diefendorf D, Apthorp J et al. Analysis of 429 fractures in 189 battered children.  J Pediatr Orthop. 1988;  8(5) 585-589 PubMed PMID: 3170740
    Search in Google Scholar
  • 12 Kleinmann P K. Diagnostic imaging of child abuse 1995. 2nd ed. St. Lewis: Mosby; 1998
    Search in Google Scholar
  • 13 Cohen R A, Kaufman R A, Myers P A, Towbin R B. Cranial computed tomography in the abused child with head injury.  AJR Am J Roentgenol. 1986;  146(1) 97-102 PubMed PMID: 3510048
    Search in Google Scholar
  • 14 Arnholz D, Hymel K P, Hay T C, Jenny C. Bilateral pediatric skull fractures: accident or abuse?.  J Trauma. 1998;  45(1) 172-174 PubMed PMID: 9680036
    Search in Google Scholar
  • 15 Hobbs C J. Skull fracture and the diagnosis of abuse.  Arch Dis Child. 1984;  59(3) 246-252 PubMed PMID: 6 712 273, PubMed Central PMCID: PMC1628552
    Search in Google Scholar
  • 16 Boal D KB. Child abuse.. In: Caffey’s pediatric diagnostic imaging. 10th ed. Philadelphia: Mosby; 2004
    Search in Google Scholar
  • 17 Kleinman P K, Spevak M R. Soft tissue swelling and acute skull fractures.  J Pediatr. 1992;  121(5 Pt 1) 737-739 PubMed PMID: 1432424
    Search in Google Scholar
  • 18 Duhaime A C, Alario A J, Lewander W J et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age.  Pediatrics. 1992;  90 179-185
    Search in Google Scholar
  • 19 Mayr J M, Seebacher U, Lawrenz K et al. Bunk beds – a still underestimated risk for accidents in childhood?.  Eur J Pediatr. 2000;  159(6) 440-443 PubMed PMID: 10867850
    Search in Google Scholar
  • 20 Boos S C. Biomechanics of non-accidental head trauma: a work in progress.. In: Gyrations 2 : 2–4. . http://www.aspnr.org Accessed 3 .Dec.2007
    Search in Google Scholar
  • 21 Hobbs C, Childs A M, Wynne J et al. Subdural haematoma and effusion in infancy: an epidemiological study.  Arch Dis Child. 2005;  90(9) 952-955 PubMed PMID: 16 113 132, PubMed Central PMCID: PMC1720567
    Search in Google Scholar
  • 22 Dashti S R, Decker D D, Razzaq A, Cohen A R. Current patterns of inflicted head injury in children.  Pediatr Neurosurg. 1999;  31(6) 302-306 PubMed PMID: 10702730
    Search in Google Scholar
  • 23 Zimmerman R D, Russell E J, Yurberg E, Leeds N E. Falx and interhemispheric fissure on axial CT: II. Recognition and differentiation of interhemispheric subarachnoid and subdural hemorrhage.  Am J Neuroradiol. 1982;  3(6) 635-642 PubMed PMID: 6816040
    Search in Google Scholar
  • 24 Shugerman R P, Paez A, Grossman D C et al. Epidural hemorrhage: is it abuse?.  Pediatrics. 1996;  97(5) 664-668 PubMed PMID: 8628604
    Search in Google Scholar
  • 25 Matschke J, Voss J, Obi N et al. Nonaccidental head injury is the most common cause of subdural bleeding in infants < 1 year of age.  Pediatrics. 2009;  124(6) 1587-1594 PubMed PMID: 19948629
    Search in Google Scholar
  • 26 Punt J, Bonshek R E, Jaspan T et al. The ‘unified hypothesis’ of Geddes et al. is not supported by the data.  Pediatr Rehabil. 2004;  7(3) 173-184 Review, PubMed PMID: 15204569
    Search in Google Scholar
  • 27 Richards P G, Bertocci G E, Bonshek R E et al. Shaken baby syndrome.  Arch Dis Child. 2006;  91(3) 205-206 Review, PubMed PMID: 16492880, PubMed Central PMCID: PMC2065913
    Search in Google Scholar
  • 28 Geddes J F, Tasker R C, Hackshaw A K et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’?.  Neuropathol Appl Neurobiol. 2003;  29(1) 14-22 Erratum in: Neuropathol Appl Neurobiol 2003; 29(3): 322, PubMed PMID: 12581336
    Search in Google Scholar
  • 29 Harding B, Risdon R A, Krous H F. Shaken baby syndrome.  BMJ. 2004;  328(7442) 720-721 PubMed PMID: 15044268, PubMed Central PMCID: PMC381309
    Search in Google Scholar
  • 30 Case M E, Graham M A, Handy T C et al. Position paper on fatal abusive head injuries in infants and young children.  Am J Forensic Med Pathol. 2001;  22(2) 112-122 PubMed PMID: 11394743
    Search in Google Scholar
  • 31 Hymel K P, Jenny C, Block R W. Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies.  Child Maltreat. 2002;  7(4) 329-348 Review, PubMed PMID: 12408245
    Search in Google Scholar
  • 32 Duhaime A C, Christian C, Armonda R et al. Disappearing subdural hematomas in children.  Pediatr Neurosurg. 1996;  25(3) 116-122 PubMed PMID: 9144709
    Search in Google Scholar
  • 33 Stoodley N. Controversies in non-accidental head injury in infants.  Br J Radiol. 2006;  79(943) 550-553 Review, PubMed PMID: 16823058
    Search in Google Scholar
  • 34 Ewing-Cobbs L, Prasad M, Kramer L et al. Acute neuroradiologic findings in young children with inflicted or noninflicted traumatic brain injury.  Childs Nerv Syst. 2000;  16(1) 25-33 discussion 34, PubMed PMID: 10672426
    Search in Google Scholar
  • 35 Kemp A M, Stoodley N, Cobley C et al. Apnoea and brain swelling in non-accidental head injury.  Arch Dis Child. 2003;  88(6) 472-476 discussion 472–476, PubMed PMID: 12765909, PubMed Central PMCID: PMC1763133
    Search in Google Scholar
  • 36 Stoodley N. Non-accidental head injury in children: gathering the evidence.  Lancet. 2002;  360(9329) 271-272 PubMed PMID: 12147367
    Search in Google Scholar
  • 37 Zimmerman R D, Yurberg E, Russell E J, Leeds N E. Falx and interhemispheric fissure on axial CT: I. Normal anatomy.  AJR Am J Roentgenol. 1982;  138(5) 899-904 PubMed PMID: 6979177
    Search in Google Scholar
  • 38 Ravid S, Maytal J. External hydrocephalus: a probable cause for subdural hematoma in infancy.  Pediatr Neurol. 2003;  28(2) 139-141 PubMed PMID: 12699866
    Search in Google Scholar
  • 39 Amodio J, Spektor V, Pramanik B et al. Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces.  Pediatr Radiol. 2005;  35(11) 1113-1137 Epub 2005 May 19, PubMed PMID: 15902432
    Search in Google Scholar
  • 40 Piatt J H. A pitfall in the diagnosis of child abuse: external hydrocephalus subdural hematoma and retinal hemorrhages.  Neurosurg Focus . 1999;  7(4) 4 PubMed PMID: 16918219
    Search in Google Scholar
  • 41 Rooms L, Fitzgerald N, McClain K L. Hemophagocytic lymphohistiocytosis masquerading as child abuse: presentation of three cases and review of central nervous system findings in hemophagocytic lymphohistiocytosis.  Pediatrics. 2003;  111(5 Pt 1) 636-640 Review, PubMed PMID: 12728123
    Search in Google Scholar
  • 42 Knapp J F, Soden S E, Dasouki M J, Walsh I R. A 9-month-old baby with subdural hematomas, retinal hemorrhages, and developmental delay.  Pediatr Emerg Care. 2002;  18(1) 44-47 PubMed PMID: 11862140
    Search in Google Scholar
  • 43 Parker L A. Part 1: early recognition and treatment of birth trauma: injuries to the head and face.  Adv Neonatal Care. 2005;  5(6) 288-297 quiz 298–300, Review, Erratum in: Adv Neonatal Care 2006; 6(1): 56, PubMed PMID: 16338668
    Search in Google Scholar
  • 44 Whitby E H, Griffiths P D, Rutter S et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors.  Lancet. 2004;  363(9412) 846-851 PubMed PMID: 15031028
    Search in Google Scholar
  • 45 Holden K R, Titus M O, Van Tassel P. Cranial magnetic resonance imaging examination of normal term neonates: a pilot study.  J Child Neurol. 1999;  14(11) 708-710 PubMed PMID: 10593546
    Search in Google Scholar
  • 46 Levin A V. Retinal hemorrhage in abusive head trauma.  Pediatrics. 2010;  126(5) 961-970 Epub 2010 Oct 4, Review, PubMed PMID: 20921069
    Search in Google Scholar
  • 47 Holbourn A HS. Mechanics of head injuries.  Lancet. 1943;  2 438-441
    Search in Google Scholar
  • 48 Case M E, Graham M A, Handy T C; et al. Position paper on fatal abusive head injuries in infants and young children.  Am J Forensic Med Pathol. 2001;  22(2) 112-122 PubMed PMID: 11394743
    Search in Google Scholar
  • 49 Calder I M, Hill I, Scholtz C L. Primary brain trauma in non-accidental injury.  J Clin Pathol. 1984;  37(10) 1095-1100 PubMed PMID: 490948, PubMed Central PMCID: PMC498946
    Search in Google Scholar
  • 50 Lindenberg R, Freytag E. Morphology of brain lesions from blunt trauma in early infancy.  Arch Pathol. 1969;  87(3) 298-305 PubMed PMID: 5766255
    Search in Google Scholar
  • 51 Adams J H, Graham D I, Murray L S, Scott G. Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases.  Ann Neurol. 1982;  12(6) 557-563 PubMed PMID: 7159059
    Search in Google Scholar
  • 52 Shannon P, Smith C R, Deck J et al. Axonal injury and the neuropathology of shaken baby syndrome.  Acta Neuropathol. 1998;  95(6) 625-631 PubMed PMID: 9650755
    Search in Google Scholar
  • 53 Section of Radiology, American Academy of Pediatrics 2009 . Diagnostic imaging of child abuse.  Pediatrics. 2009;  123 1430-1435
    Search in Google Scholar
  • 54 Aldrich E F, Eisenberg H M, Saydjari C et al. Diffuse brain swelling in severely head-injured children. A report from the NIH Traumatic Coma Data Bank.  J Neurosurg. 1992;  76(3) 450-454 PubMed PMID: 1738026
    Search in Google Scholar
  • 55 Kemp A M. Investigating subdural haemorrhage in infants.  Arch Dis Child. 2002;  86(2) 98-102 Review, PubMed PMID: 11827902, PubMed Central PMCID: PMC1761066
    Search in Google Scholar
  • 56 Jaspan T, Griffiths P D, McConachie N S, Punt J A. Neuroimaging for non-accidental head injury in childhood: a proposed protocol.  Clin Radiol. 2003;  58(1) 44-53 PubMed PMID: 12565205
    Search in Google Scholar
  • 57 Stoodley N. Neuroimaging in non-accidental head injury: if, when, why and how.  Clin Radiol. 2005;  60(1) 22-30 Review, PubMed PMID: 15642289
    Search in Google Scholar
  • 58 Campbell K A, Bogen D L, Berger R P. The other children: a survey of child abuse physicians on the medical evaluation of children living with a physically abused child.  Arch Pediatr Adolesc Med. 2006;  160(12) 1241-1246 PubMed PMID: 17146021
    Search in Google Scholar
  • 59 Hamilton-Giachritsis C E, Browne K D. A retrospective study of risk to siblings in abusing families.  J Fam Psychol. 2005;  19(4) 619-624 PubMed PMID: 16402877
    Search in Google Scholar
  • 60 Bonnier C, Nassogne M C, Saint-Martin C et al. Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome.  Pediatrics. 2003;  112(4) 808-814 Review, PubMed PMID: 14523171
    Search in Google Scholar
  • 61 Hymel K P, Abshire T C, Luckey D W, Jenny C. Coagulopathy in pediatric abusive head trauma.  Pediatrics. 1997;  99(3) 371-375 PubMed PMID: 9041291
    Search in Google Scholar
  • 62 Poussaint T Y, Moeller K K. Imaging of pediatric head trauma.  Neuroimaging Clin N Am. 2002;  12(2) 271-294 ix, Review, PubMed PMID: 12391636
    Search in Google Scholar
  • 63 Lowe L H, Bulas D I. Transcranial Doppler imaging in children: sickle cell screening and beyond.  Pediatr Radiol. 2005;  35(1) 54-65 Epub 2004 Aug 24, Review, PubMed PMID: 15338082
    Search in Google Scholar
  • 64 Conway J J, Collins M, Tanz R R et al. The role of bone scintigraphy in detecting child abuse.  Semin Nucl Med. 1993;  23(4) 321-333 Review, PubMed PMID: 8256139
    Search in Google Scholar
  • 65 Bradley W G. MR appearance of hemorrhage in the brain.  Radiology . 1993;  189(1) 15-26 Review, PubMed PMID: 8372185
    Search in Google Scholar
  • 66 Suh D Y, Davis P C, Hopkins K L et al. Nonaccidental pediatric head injury: diffusion-weighted imaging findings.  Neurosurgery. 2001;  49(2) 309-318 discussion 318–320, PubMed PMID: 11504106
    Search in Google Scholar
  • 67 Barnes P D, Krasnokutsky M. Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics.  Top Magn Reson Imaging. 2007;  18(1) 53-74 Review, PubMed PMID: 17607143
    Search in Google Scholar
  • 68 Vezina G. Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI.  Pediatr Radiol. 2009;  39(6) 586-590 Epub 2009 Mar 21, PubMed PMID: 19305988
    Search in Google Scholar
  • 69 Tung G A, Kumar M, Richardson R C et al. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography.  Pediatrics. 2006;  118(2) 626-633 PubMed PMID: 16882816
    Search in Google Scholar
  • 70 Williams V L, Hogg J P. Magnetic resonance imaging of chronic subdural hematoma.  Neurosurg Clin N Am. 2000;  11(3) 491-498 Review, PubMed PMID: 10918019
    Search in Google Scholar
  • 71 Kleinman P K, Ragland R L. Gadopentetate dimeglumine-enhanced MR imaging of subdural hematoma in an abused infant.  AJR Am J Roentgenol. 1996;  166(6) 1456-1458 PubMed PMID: 8633463
    Search in Google Scholar
  • 72 Feldman K W, Bethel R, Shugerman R P et al. The cause of infant and toddler subdural hemorrhage: a prospective study.  Pediatrics. 2001;  108(3) 636-646 PubMed PMID: 11533330
    Search in Google Scholar
  • 73 Vinchon M, Noulé N, Tchofo P J et al. Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse.  J Neurosurg. 2004;  101(1 Suppl) 44-52 PubMed PMID: 16206971
    Search in Google Scholar
  • 74 Zouros A, Bhargava R, Hoskinson M, Aronyk K E. Further characterization of traumatic subdural collections of infancy. Report of five cases.  J Neurosurg. 2004;  100(5 Suppl Pediatrics) 512-518 PubMed PMID: 15287465
    Search in Google Scholar
  • 75 Barnes P D, Robson C D. CT findings in hyperacute nonaccidental brain injury.  Pediatr Radiol. 2000;  30(2) 74-81 PubMed PMID: 10663515
    Search in Google Scholar
  • 76 Schaper J, Heinen W. Normvarianten und nichtpathologische Befunde des kindlichen Skeletts.  Radiologie up2date. 2006;  6 288
    Search in Google Scholar

Dr. med. Dirk Klee

Universitätsklinikum Düsseldorf
Kinderradiologie des Instituts für Diagnostische und Interventionelle Radiologie

Moorenstr. 5
40225 Düsseldorf

Phone: +49 211 811-7665, -04052

Fax: +49 211 811-9293

Email: Dirk.Klee@med.uni-duesseldorf.de