Slide 1 - Home - Kuwait Child's Rights Society

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Slide 1 - Home - Kuwait Child's Rights Society

  1. 1. NEUROSURGICAL ASPECTS OF CHILD ABUSE Tarik Al-Sheikh, FRCS, FRCS (N.S) Department of Neurosurgery Ibn Sina Hospital-Kuwait
  2. 2. • Child Abuse =Non-accidental head injury (NAI) =Inflected Injury =Abusive injury =Abusive head trauma (AHT) =Shaken baby syndrome (SBS) =Battered child syndrome
  3. 3. • Sensitive/ Difficult/ Controversial • Stressful to clinician/ Legal issues +Medicine • Unfamiliar/ Uncomfortable • Deliberate or not? • Catastrophic outcome life-long!! • Little experience • You don’t imagine/ expect it
  4. 4. Definition • Children presenting with a complex of signs and symptoms resulting from mis- treatment by their caretakers
  5. 5. • 1930’s-1940’s • Kempe 1962 History
  6. 6. Infantile SDH+ Long bones # + Retinal hemorrhage Caffey (1946-1974) History (cont.)
  7. 7. Epidemiology • Difficult!! -Ascertainment -Inclusion criteria -Follow-up
  8. 8. Epidemiology (cont.) 24.6/ 100 000 children <1 yr /YearScotland 100-200 cases/ YearGermany ˷ 50 000 SBS/ Year (600-1400 infants of SBS/ A&E/ Year) USA 903 000 children-1300 deathsWorldwide (2001) 1/4065AHT risk by 1 year
  9. 9. • <2 yrs + HI → 24% due to AHT • Mortality 19-30% →40% < 1 year • Perm. brain damage 30% • Perm. mild effect 30% Epidemiology (cont.)
  10. 10. Epidemiology (cont.) •Kuwait (1987) •W. Al-Ateeqi et al. (2002) •1991-1998; 60640 records •16 children- AHT (38%-5 cases) •7 lost follow-up •2 died
  11. 11. Profile/ Risk Factors • Young Parents (20’s) • Low S-E status • Unstable household • Single parents • Premature infants • Prolonged stay in NICU • Infants<1 year • Infant disability • H/O abuse of the caretaker • Psychiatric history • Drug abuse • Urban> Rural • Boys> Girls • Autumn + Winter
  12. 12. • Fathers 37% • Boyfriends 20.5% • Female babysitters 17.3% • Mothers 12.6% Perpetrators
  13. 13. • Physical examination conflicting the caretaker story • True story is missing!! • Clinician works as police interrogator!! • Story: 1. Trivial blunt trauma (i.e. Short-height fall) 2. No H/O trauma Clinical Presentation
  14. 14. Clinical Presentation (cont.) Diagnosis is missed in: •Young Infants •Caucasian •Presence of both parents •Insurance status •No apnea/ no seizures
  15. 15. Clinical Presentation (cont.) •Variable→ Severity •Poor feeding/ vomiting •Failure to thrive •Lethargy/ irritability •Hypothermia/ chills •Failure to smile/ verbalize •Increased sleeping •Seizures/abnormal movements •Resp. difficulty/ apnea •Bradycardia •Bulging fontanelle •Large head circumference •Coma •Cardiovascular collapse
  16. 16. Clinical Presentation (cont.) • Initial contact gives the best chance for history!! • In-depth specific questions: What? When? Who? How? Where? • Tailor evaluation/ management + anticipate potential delayed complications
  17. 17. Imaging *X-ray: skull, long bones, chest, spines *CT: brain, chest- REPEAT! *Ultrasound: head, abdomen *MRI: brain, spines- REPEAT!! *Radioisotope bone scan
  18. 18. Diagnostic signs • Acute SDH: thin, posterior interhemispheric. • Brain hypodensity: focal/ patchy/ extensive (1-2 days) • Intracranial injury in the absence of accidental trauma
  19. 19. • Acute SDH + healing skeletal fractures + retinal hemorrhage (+ detachment)-only in NAI!! • Low-height fall → skull #; EDH But never acute SDH, brain swelling, brain hypodensity Diagnostic signs (cont.)
  20. 20. • Penetrating • Direct Impact NAI • Inertial (SBS) Head Injury Mech.
  21. 21. Children fall repeatedly without head injury!!!: - Large head -Weak cervical muscles -Wide SD space -Deformable skull →Torn/ stretched veins + axonal injury + stretched cranio- cervical junction (brain stem) → Bleeding Ischemic events Apnea/ hypoxia Head Injury Mech. (cont) + REPEATED FORCEFUL INSULTS
  22. 22. Evaluation/ Management • ABC • Glasgow Coma Scale (GCS) • Prevent 2° brain insult:  BP  O2  Na+ Seizures Edema • Evacuate acute SDH Aspiration Burrhole Craniotomy/ Craniectomy DOCUMENT/ REPORT TO AUTHORITY
  23. 23. Evaluation/ Management (cont.) TEAM WORK • Pediatrician expert in child abuse • Pediatric neurosurgeon • Pediatric radiologist • Ophthalmologist • Child protection staff
  24. 24. • Bacterial/ viral infections • Bleeding disorders • Cerebral aneurysm • Osteogenesis imperfecta • Metabolic disorders • Accidental injury Differential Diagnosis
  25. 25. Medico-Legal • Civil proceedings • Criminal proceedings - Consistent - Presumptive - Suspicious (indeterminate)
  26. 26. Prognosis • NAI is worse than accidental injuries • Worse prognosis with apnea/ seizures/ brain hypodensity • 30% Death • Blindness • Deafness • Paralysis • Mental retardation • Seizures • Develop. Delay • Parkinson’s disease • Memory/attention/speech/learning problems
  27. 27. 1-Primary: Teach all parents 2-Secondary: Teach population at risk 3-Tertiary: Teach families involved Prevention

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