Tessa Sieswerda-Hoogendoorn

Current techniques in postmortem imaging with specific attention to paediatric applications

In this review we discuss the decline of and current controversies regarding conventional autopsies and the use of postmortem radiology as an adjunct to and a possible alternative for the conventional autopsy. We will address the radiological techniques and applications for postmortem imaging in children.

Educational paper: Imaging child abuse: the bare bones

Fractures are reported to be the second most common findings in child abuse, after skin lesions such as bruises and contusions. This makes careful interpretation of childhood fractures in relation to the provided clinical history important. In this literature review, we address imaging techniques and the prevailing protocols as well as fractures, frequently seen in child abuse, and the differential diagnosis of these fractures. The use of a standardised protocol in radiological imaging is stressed, as adherence to the international guidelines has been consistently poor. As fractures are a relatively common finding in childhood and interpretation is sometimes difficult, involvement of a paediatric radiologist is important if not essential. Adherence to international guidelines necessitates review by experts and is therefore mandatory. As in all clinical differential diagnoses, liaison between paediatricians and paediatric radiologists in order to obtain additional clinical information or even better having joint review of radiological studies will improve diagnostic accuracy. It is fundamental to keep in mind that the diagnosis of child abuse can never be solely based on radiological imaging but always on a combination of clinical, investigative and social findings. The quality and interpretation, preferably by a paediatric radiologist, of radiographs is essential in reaching a correct diagnosis in cases of suspected child abuse.

Age determination of subdural hematomas with CT and MRI: A systematic review

OBJECTIVES To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI scans. METHODS We performed a systematic review in MEDLINE, EMBASE and Cochrane to search for articles that described the appearance of SDHs on CT or MRI in relation to time between trauma and scanning. Two researchers independently screened the articles, assessed methodological quality and performed data extraction. Medians with interquartile ranges were calculated. Differences were tested with a Mann-Whitney U or Kruskal-Wallis H test. RESULTS We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences between time intervals for the different densities on CT (p<0.001). Time interval differed significantly between children and adults for iso- and hypodensity (p=0.000) and hyperdensity (p=0.046). Time interval did not differ significantly between abused and non-abused children. On MRI, time intervals for different signal intensities on T1 and T2 did not differ significantly (p=0.108 and p=0.194, respectively). CONCLUSIONS Most time intervals of the different appearances of SDHs on CT and MRI are broad and overlapping. Therefore CT or MRI findings cannot be used to accurately date SDHs.

Educational paper : Abusive Head Trauma Part II: Radiological aspects

Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

The value of post-mortem CT in neonaticide in case of severe decomposition: Description of 12 cases

INTRODUCTION In cases of neonaticide with delayed finding of the body, interpretation of autopsy results can be difficult because of decomposition. Postmortem computed tomography (PMCT) has become an increasingly popular tool in the (pediatric) forensic field. We performed a retrospective study to compare the outcome of PMCT with autopsy results in suspected neonaticide, in neonates found more than one week after their demise. We compared the performance of both methods on (1) determining gestational age, (2) differentiating between live birth and still birth and (3) determining cause of death. METHOD We selected all consecutive neonaticide cases with an estimated postmortem interval longer than one week, who underwent a forensic autopsy including a total body PMCT in the Netherlands Forensic Institute in the period 2008-2012. Both a pathologist and radiologist scored gestational age, signs of live birth and cause of death for each case. RESULTS 22 cases of neonaticide were identified in the study period, of which 15 cases were estimated to be found more than 1 week after death. In 12 of these a total body PMCT was performed. In all cases, late postmortem changes were present. Gestational age could be assessed with PMCT in 100% of the cases and with autopsy in 58% of the cases. In all cases neither PMCT nor autopsy was able to assess live birth and cause of death. CONCLUSION PMCT is a better tool for estimating gestational age in case of suspected neonaticide with late postmortem changes compared to autopsy and should therefore be a standard part of the work-up. Signs of live birth and cause of death could not be determined with neither of the methods, an adjusted post mortem examination including limited autopsy for these cases might be developed.

Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse

We investigated the prevalence of risk factors for and the prevalence of prior abuse in abusive head trauma victims in the Netherlands.

Prevalence of child sexual abuse in pediatric patients with chronic abdominal pain

Background and Objectives: A history of sexual abuse is to be found in approximately 40% of all adult patients with gastrointestinal complaints. Data on the prevalence of child sexual abuse (CSA) in children with chronic abdominal pain (CAP) are lacking. The objective of this systematic review is to determine the prevalence of CSA in pediatric patients with CAP. Methods: We conducted a systematic literature search in the electronic databases MEDLINE, EMBASE, PsychInfo, and ERIC. Reference lists of relevant articles were scanned for additional citations. We selected case-control, cohort and cross-sectional studies investigating the prevalence of CSA in children with CAP, ages 0 to 18 years. Data were extracted from relevant studies, which were assessed for methodological quality by 2 independent reviewers. Prevalence of CSA was the main outcome measure. Results: The literature search yielded a total of 269 articles. Only 2 studies met our inclusion criteria, reporting CSA in 2.1% and 8.0% of children (age range 4–21 years) with CAP. Both studies were conducted in small groups (n = 48 and n = 50) without control group(s) and did not use standardized or validated instruments for diagnosing CSA. Conclusions: According to existing data, the prevalence of a history of CSA in pediatric patients with CAP is lower than in adult patients; however, no well-designed studies have been conducted in children. Future research is required to determine a reliable prevalence of CSA in children with CAP.

Normal cranial postmortem CT findings in children

INTRODUCTION Postmortem imaging (both CT and MRI) has become a widely used tool the last few years, both for adults and children. If it would be known which findings are normal postmortem changes, interpretation of abnormal findings becomes less ambiguous. Our aim was to describe postmortem intracranial radiological findings on postmortem CT (PMCT) in children, which did not have a relationship with the cause of death, and to determine whether these findings have a relationship with the postmortem interval or with medical interventions. MATERIALS AND METHODS We selected all consecutive pediatric autopsies that were performed at the Netherlands Forensic Institute in the period 1-1-2008 to 31-12-2011, whereby the subject underwent total body PMCT. We collected data on age at death, gender, cause of death determined by forensic autopsy and time between death and PMCT. Normal findings that were scored were: gray-white differentiation of the brain, collapse of the ventricles, air in the orbit, fluid accumulation in the frontal and maxillary sinuses, and air in vessels of head and neck. RESULTS One-hundred-fifty-nine forensic pediatric autopsies were performed in the 4 year study period at the NFI; 77 underwent a total body PMCT, of which 68 were included in the analyses. Fluid accumulation in the sinuses was present 30-40% of the cases in which the sinuses were developed. In 22% of all children intravascular intracranial air, either arterial or venous, was detected. We did not find a relationship between the duration of the postmortem interval and the appearance of any of the findings. Intravenous infusion is not significantly associated with the presence of intravascular air, except for air in the left and right common carotid artery (B=2.9, P=0.05). CONCLUSIONS By demonstrating the intracranial abnormalities that appear postmortem, we have tried to provide more insight in the range of findings that can be seen with pediatric PMCT. As these findings resemble antemortem pathology, it is important that the radiologist who interprets PMCT has knowledge of these normal postmortem findings.

Abusive head trauma: Differentiation between impact and non-impact cases based on neuroimaging findings and skeletal surveys

OBJECTIVES To determine whether imaging findings can be used to differentiate between impact and non-impact head trauma in a group of fatal and non-fatal abusive head trauma (AHT) victims. METHODS We included all AHT cases in the Netherlands in the period 2005-2012 for which a forensic report was written for a court of law, and for which imaging was available for reassessment. Neuroradiological and musculoskeletal findings were scored by an experienced paediatric radiologist. RESULTS We identified 124 AHT cases; data for 104 cases (84%) were available for radiological reassessment. The AHT victims with a skull fracture had fewer hypoxic ischaemic injuries than AHT victims without a skull fracture (p=0.03), but the relative difference was small (33% vs. 57%). There were no significant differences in neuroradiological and musculoskeletal findings between impact and non-impact head trauma cases if the distinction between impact and non-impact head trauma was based on visible head injuries, as determined by clinical examination, as well as on the presence of skull fractures. CONCLUSIONS Neuroradiological and skeletal findings cannot discriminate between impact and non-impact head trauma in abusive head trauma victims.

Pneumomediastinum and soft tissue emphysema in pediatric hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3‐year‐old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.