Contribution of cranial MR in combination with CT in the initial evaluation of infants and children with non-accidental cerebral injury (NACI): Correlation with presence of retinal hemorrhages (RH) Anil Kilpadikar, MD, Toss Worthington, RN, Jerry G. Jones, MD, Charles M. Glasier, MD

Introduction: Non-accidental Cerebral Injury (NACI)

• NACI is the leading cause of death (USA) in children under 2 years of age.
• In children less than 1 year old, 95% of all serious head injuries and 64% of all head injuries result from maltreatment.
• Outcome of infants suffering NACI is considerably worse than for those of the same age who have sustained ACI.

Purpose: Retrospectively study a large group of infants and children with documented NACI who had cranial CT, MR, and ophthalmologic exam as part of an initial evaluation in order to determine added utility of acute cranial MR, if any, and significance of retinal hemorrhage for prediction of severity of cerebral injury.

Matherials and Methods:

• 95 consecutive infants and children age newborn to 4 years admitted from 1999-2003 with documented NACI were reviewed.
• 40 children in this group who had concurrent CT and MR near the time of admission were included in the study.
• CT exams were performed on the day of admission without contrast or sedation.
• MR was performed within an average of 51 hrs. of the admission CT (range 0-12 days).
• MR performed on a 1.5T magnet.
• Sequences included sagittal T1W, axial PD or FLAIR, T2W and GE images in all cases.
• 27/40 (68%) had DW imaging.
• 3/40 (7.5%) had MRA.
• None had spectroscopy.
• Patient records, CT, and MR reports were reviewed retrospectively with specific attention to EDH, SDH, parenchymal hemorrhage (PH), cerebral ischemic change (CIC), and retinal hemorrhage (RH).
• Presence of RH was correlated with severity of cerebral injury.
• Maximum cerebral injury score of 3 included presence of SDH or EDH (1 point), PH (1 point), and CIC (1 point).

Results:

• 30/40 (75%) had SDH.
• 15/40 (38%) had CIC.
• 9/40 (23%) had PH.
• 3/40 (8%) had EDH.
• In all cases CT and MR both detected EDH, SDH, and PH.
• In patients with CIC, CT was positive in 7/15 (47%) and MR positive in 15/15 (100%) cases, which is statistically significant (p<0.05).
• 18/40 patients with RH had a higher cerebral injury score (1.72) than 22/40 patients without RH (0.85), which is statistically significant (p<0.05).

Conclusion:

• Although CT and MR each detected all cases of EDH, SDH, and PH, MR detected over twice as many cases of CIC as compared to CT, a statistically significant finding indicating added value for the MR examination in acute setting.
• Presence of RH was associated with a statistically significant increase in severity of cerebral injury.

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