martedì 20 novembre 2007

Shaken-baby syndrome


Bilateral orbital hyper densities (retinal hemorrhage), loss of grey-white matter differentiation and effacement of the basal cisterns and ventricles (hypoxic ischemic injury, cerebral edema, impending herniation), left convexity cortical contusions / SAH, interhemispheric SDH.

Differential diagnosis:
- Non-accidental trauma
- Accidental trauma
- Hemophilia
- Hypoprothrombinemia
- Glutaric aciduria
- Osteogenesis imperfecta
- Leukemia

Diagnosis: Shaken-baby syndrome (non-accidental trauma)

Key points

The constellation of retinal hemorrhage, SDH, and long-bone metaphyseal fractures were initially described by Caffey as "whiplash shaken injury." Non-accidental trauma is the most common cause of traumatic death in infancy.
Risk factors: Prematurity, < 12 mos, young parents, low socioeconomic status, twin, male, disability.
Perpetrators: father > boyfriend > babysitter > mother.
Common presentation: "unresponsive" – upper cervical cord stretching causing apnea causing ischemic brain injury (60% mortality if comatose at presentation).

Neurologic manifestations include:
- SDH (highly specific if of various ages/locations, convexities / posterior interhemispheric fissure common).
- Retinal hemorrhage (usually bilateral, always associated with SDH).
- Cortical contusions.
- Hypoxic ischemic encephalopathy with loss of grey-white differentiation and overall decreased cerebral attenuation with sparing of posterior fossa; effacement of sulci/ventricles/cisterns.
- Skull fractures and EDH are uncommon.

Plain film is more sensitive that CT in detecting skull fractures.
Skeletal survey should always be obtained if NAT is suspected.

Differential Diagnosis for retinal hemorrhage w/ SDH:
- accidental trauma (consider concordance of history given vs. severity of injury)
- coagulopathies (blood dyscrasias, leukemia)
- resuscitative efforts (retinal hemorrhage only)
- osteogenesis imperfecta (skeletal manifestations predominate)
- inborn errors of metabolism (glutaric aciduria type I associated with SDH only)

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