A short presentation summarising the main findings of the consensus paper on abusive head trauma, the controversies raised by the SBU report about triad and "shaken baby syndrome" and main criticisms moved against SBU report. A useful summary for radiologists and clinicians involved in child abuse. Presented at the Pediatric Neuroradiology PanLondon Sunset Meeting July 2019

1. SBU and beyond…
felice.d’arco@gosh.nhs.uk

2. WHO: Radiologists, Pediatric
Neuroradiologists, Law experts,
Pediatricians, MSK radiologists,
Pediatric Neurosurgeons
“This consensus statement,
supported by the Society for
Pediatric Radiology (SPR),
European Society of Paediatric
Radiology (ESPR), American
Society of Pediatric
Neuroradiology (ASPNR),
American Academy of Pediatrics
(AAP), European Society of
Neuroradiology (ESNR),
American Professional Society
on the Abuse of Children
(APSAC), Swedish Paediatric
Society, Norwegian Pediatric
Association and Japanese
Pediatric Society”

3. Conclusions
1) Abusive head trauma (AHT) is the current most appropriate and
inclusive diagnostic term for infants and young children who
suffer from inflicted intracranial and associated spinal injury.
This does not negate the mechanisms of shaking or shaking with
impact as a significant mechanism of injury but merely indicates that
the term “shaken baby” is not all-inclusive
Why?
“Currently, the medical literature and overwhelming clinical experience
and judgment demonstrate that AHT can be caused by shaking alone,
shaking with impact, or blunt impact alone.”
“AHT is a scientifically
non-controversial medical
diagnosis broadly recognized
and managed throughout the
world.”

4. 2) Lack of history, changing history or the incompatibility
of history (i.e. short falls) with the severity of injury raise
concerns for possible AHT.
3) Relatively few infants with AHT have isolated intracranial
injury without retinal hemorrhages, fractures or other
manifestations of child abuse.
4) No single injury is diagnostic of AHT.
5) Each infant suspected of suffering AHT must be further
evaluated for other diseases that might present with similar
findings.
Conclusions

5. Controversies
Selection method??? Consensus
vs Systematic Review

6. Controversies
CT hyperdensity
“the disappearance of the last hyperattenuated component was
identified between 2 days and 40 days after injury.”
Wittschieber et al. 2019

7. Controversies
CT hyperdensity
“the disappearance of the last hyperattenuated component was
identified between 2 days and 40 days after injury.”
Wittschieber et al. 2019

10. Some response papers…good to know them

11. Critic to SBU
Supportive of
SBU
2 editorials on
the same
journal…

12. SBU: It already hit the news… and was already used in tribunal at least twice

13. Triad exclusively attributed to
isolated traumatic shaking: WRONG
QUESTION!
They created novel entity: Isolated
Traumatic Shaking (making
impossible to identify relevant
studies)
Misquoted references : main age of
children < 12 (Park et al says is peak
age)
Main criticisms to
the SBU reports
(RCPCH response))

14. “Triad”and Encephalopathy never
fully defined in methods (search
terms bias!)
Unrealistic Reference Gold
Standard: admitted or witnessed
traumatic shaking
Implies that in absence of admitted
or witnessed traumatic shaking
there was no shaking!

15. Minimum 10 pts threshold but case
reports used in DDX for triad
Search strategy/PIRO:
NO: encephalopathy , accidental and
non-accidental injury, witnessed,
admitted shaking
YES: cerebral/brain oedema (not a
clinical indicator)

16. Speaking about mimics….
Delta Storage Pool
Disease
K Vit Deficiency
Hepatitis…wait for
it
Vascular
malformations
Only 5 presented
with triad!

17. “US revealed unilateral SDH with midline shift and brain oedema ”
A large unilateral
subdural
haematoma
creating midline
shift and secondary
to coagulation
problem!!
Completely different
from the “triad” in
AHT

18. “Authors do not take into
account the type of RE:
multilayered, numerous,
extending to ora serratam
associated with
retinoschisis”
“Multiple studies have shown that such details about retinal
haemorrhage have great diagnostic significance. To ignore
these descriptors is like saying that a rose is no different than
any other ‘flower’.”
“Authors fail to note the extremely high positive predictive
value”
“Authors misquote Vinchon saying that SDH can cause RE,
Firshing et al. and Lashutka et al saying that iICP can cause RE
(none of their patients had RE)”
“Authors used adult literature or quote presence of RE after
birth not mentioning that age is different”

19. “we know without question that abusive head trauma indeed is a
primary cause, and perhaps the most common cause of retinal
haemorrhages in young children beyond the neonatal period.”
Conclusions
“A diagnosis of abuse should not be made solely based on
retinal haemorrhages, but certain retinal findings make that
likelihood dramatically high, so high that one must actively
seek (or rule out) supportive evidence that the child has been
abused and is inneed of protection.”

20. Geddes Hypothesis: SDH and RH secondary to hypoxia
and raised venous pressure (this was criticized but…)
SDH can be found in young infants with HIE not
related to trauma (Scheimberg I, Cohen MC et al Ped
Develop Path 2013)
The results support the findings of Geddes and colleagues: 33% of
SDH had HIE (significant association HIE / SDH (but peripartum
complications in most of cases)

21. Timing controversies
Don’t date, not even CT…. HYPERDENSE BLOOD CT: 1 day -2
wks

22. Timing controversies
Don’t date, not even CT…. HYPO or Heterogeneous CT can be

23. Timing controversies
Only thing you can say is: membranes  cSDH (> 10 days)
“In neuropathology, the first formation of
neomembranes is described
as macroscopically visible after 10 days”

24. Conclusions
• Triad should be still considered supportive
of AHT in the right context (multidisciplinary
approach!)
• Controversies are present we should not
deny that
• Be aware of the literature (useful in
tribunal)
• What do you think of the level of
evidences?