Shortage of paediatric radiologists acting as an expert witness: position statement from the British Society of Paediatric Radiology (BSPR) National Working Group on Imaging in Suspected Physical Abuse (SPA).

One of the most challenging areas of radiological imaging in children is the diagnosis of physical abuse. There is a dearth of paediatric radiologists willing to act as expert witnesses, particularly in the family courts. There are a number of reasons why radiologists may not be interested or willing to put themselves forward to work as expert witnesses in this field. A group of imaging experts recently formed the "British Society of Paediatric Radiology (BSPR) Working Group on Imaging in Suspected Physical Abuse (SPA)". The group comprises radiologists and neuroradiologists with current or previous experience of providing expert witness reports to the court in cases of SPA. The group met in January 2019 to explore pragmatic solutions to the chronic inefficiencies in both medical and legal practices and the challenges that arise from working in a legal arena with different structures, goals, and assessment criteria. Key issues concerned organisational inefficiencies, variable support from National Health Service Trusts and the Royal College of Radiologists to conduct this work, and the risk/benefit of involvement. This work is important for the patient, parents, and society in general, and highly rewarding for clinical practitioners who are involved, but there are several issues with current practices that discourage active participation. With several members of the group either retired or close to retirement, the shortage of experts is becoming a pressing issue within the UK, which requires an engaged multidisciplinary group to come up with creative solutions. Here, the group provide a consensus opinion highlighting the current barriers and potential facilitators to increasing the number of radiologists willing to provide opinions to the court.

British Neuropathological Society and International Society of Forensic Radiology and Imaging expert consensus statement for post mortem neurological imaging.

AIMS: To develop an expert consensus statement regarding appropriate clinical and forensic post mortem neurological imaging. METHODS: An expert panel of clinicians were recruited from registered members of the British Neuropathological Society (BNS) and the International Society of Forensic Radiology and Imaging (ISFRI) with post mortem expertise. Following a focus group meeting, 16 core statements were incorporated into an online modified Delphi survey and each panellist was asked to score their level of agreement. Following the first iteration, two statements that failed to reach consensus were modified and re-rated. Consensus was predefined as 75% agreement across responders. RESULTS: Seventeen experts joined the panel and 12 (70.6%) attended the focus group meeting; 14 (82%) completed both iterations of the survey. Consensus was reached for need of adequate clinical history, multidisciplinary discussion, establishment of special interest groups to discuss cases, gathering further evidence to inform imaging choices, establishment of methods for quality assessment in reporting standards and adequate funding for imaging services. The panel agreed that pathologists should be responsible for neuroimaging referrals, collating results of ancillary tests, and producing the final post mortem report. Areas requiring further discussion include the impact of double reporting, indications for neuroimaging and utilities of three-dimensional printing. CONCLUSION: The BNS/ISFRI statement represents current views of an expert panel of health professionals engaged in post-mortem neuroimaging. We hope this provides a working guideline for less experienced operators, stimulates discussion and highlights the most pressing clinical and research questions.

Cranial neuroimaging in pregnancy and the post-partum period.

Several diverse neurological conditions may be seen during pregnancy and the post partum period. These usually require neuroimaging for definitive diagnosis and range from a predisposition to neurovascular abnormalities, such as acute ischaemic stroke and cerebral venous sinus thrombosis, through to more specific pregnancy-related conditions, such as eclampsia/posterior reversible leukoencephalopathy and post-partum angiopathy. Additionally, the pregnant patient is predisposed to pituitary disease. It is necessary that the radiologist has an awareness of these conditions to allow swift specific diagnoses or suggest the most appropriate diagnosis when imaging findings are non-specific. We describe epidemiological and radiological features to allow the radiologist to guide the clinician in management, and review guidelines for safe cranial imaging of the pregnant patient.

Thunderclap headache: diagnostic considerations and neuroimaging features.

Thunderclap headache (TCH) is an acute and severe headache that has maximum intensity at onset; TCH can be primary or secondary. Primary TCH is diagnosed when no underlying cause is discovered; however, imaging is crucial in distinguishing secondary causes, which are wide-ranging. The radiologist should be aware of the list of potential diagnoses. Subarachnoid haemorrhage (SAH) is the most common cause of secondary TCH. Aneurysmal SAH accounts for the majority of cases, although other causes should also be considered and these include perimesencephalic haemorrhage, arteriovenous malformations, and dural arteriovenous fistula as well as reversible cerebral vasoconstriction syndrome. Conditions that may present with TCH, with or without SAH include cervical artery dissection and cerebral venous sinus thrombosis. Ischaemic stroke, pituitary apoplexy, and posterior reversible leucoencephalopathy are other potential causes, whereas non-vascular causes include colloid cysts of the third ventricle and spontaneous intracranial hypotension. Imaging features are reviewed with reference to clues gleaned from initial imaging using computed tomography, as well as characteristics that should be sought using magnetic resonance imaging or angiographic imaging.

External hydrocephalus and subdural bleeding in infancy associated with transplacental anti-Ro antibodies.

BACKGROUND: The isolated finding of an unexplained chronic subdural haematoma in an infant may suggest non-accidental head injury (NAHI). The authors report a previously undescribed cause of multifocal chronic subdural haematoma in infancy which could result in a misdiagnosis of previous NAHI. METHODS: Two infants, aged 3 and 4 months of age, presented with progressively increasing head circumference measurements from birth. There was no history of encephalopathy. Retinal haemorrhages were not present. CT and MRI demonstrated bilateral subdural fluid collections over the frontal regions that were consistent with either chronic subdural haematomas or haemorrhagic subdural effusions. In view of the possibility of NAHI, child protection investigations were initiated. FINDINGS: In neither case did the child protection investigations raise concerns. Comprehensive investigations for known haematological and metabolic disorders associated with subdural haematomas or effusions in infants were all normal. In both cases the infant's mother had a history of Sjögren's syndrome and both infants had positive anti-Ro antibody at presentation. CONCLUSIONS: Transplacental acquisition of anti-Ro antibodies has been associated with external hydrocephalus. External hydrocephalus has been recognised as a predisposing factor for subdural haemorrhage. These are the first reported cases linking the presence of anti-Ro antibodies and external hydrocephalus with subdural fluid collections in infancy.

Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review.

OBJECTIVES: To identify the evidence base behind the neuroradiological features that differentiate abusive head trauma (AHT) from non-abusive head trauma (nAHT). DESIGN: Systematic review. SETTING: Literature search of 14 databases, websites, textbooks, conference abstracts and references (1970-February 2010). Studies had two independent reviews (three if disputed) and critical appraisal. PATIENTS: Primary comparative studies of children <11 years old hospitalised with AHT and nAHT diagnosed on CT or MRI. MAIN OUTCOME MEASURES: Neuroradiological features that differentiated AHT from nAHT. RESULTS: 21 studies of children predominantly <3 years old were analysed. Subdural haemorrhages (SDH) were significantly associated with AHT (OR 8.2, 95% CI 6.1 to 11). Subarachnoid haemorrhages were seen equally in AHT and nAHT and extradural haemorrhages (EDH) were significantly associated with nAHT (OR for AHT 0.1, 95% CI 0.07 to 0.18). Multiple (OR 6, 95% CI 2.5 to 14.4), interhemispheric (OR 7.9, 95% CI 4.7 to 13), convexity (OR 4.9, 95% CI 1.3 to 19.4) and posterior fossa haemorrhages (OR 2.5, 95% CI 1 to 6) were associated with AHT. Hypoxic-ischaemic injury (HII) (OR 3.7, 95% CI 1.4 to 10) and cerebral oedema (OR 2.2, 95% CI 1.0 to 4.5) were significantly associated with AHT, while focal parenchymal injury was not a discriminatory feature. SDH of low attenuation were more common in AHT than in nAHT. CONCLUSION: Multiple SDH over the convexity, interhemispheric haemorrhages, posterior fossa SDH, HII and cerebral oedema are significantly associated with AHT and should be considered together with clinical features when identifying the condition.

Band-like intracranial calcification with simplified gyration and polymicrogyria: a distinct "pseudo-TORCH" phenotype.

The combination of intracranial calcification and polymicrogyria is usually seen in the context of intrauterine infection, most frequently due to cytomegalovirus. Rare familial occurrences have been reported. We describe five patients-two male-female sibling pairs, one pair born to consanguineous parents, and an unrelated female-with a distinct pattern of band-like intracranial calcification associated with simplified gyration and polymicrogyria. Clinical features include severe post-natal microcephaly, seizures and profound developmental arrest. Testing for infectious agents was negative. We consider that these children have the same recognizable "pseudo-TORCH" phenotype inherited as an autosomal recessive trait.

Controversies in non-accidental head injury in infants.

Non-accidental head injury in infants is not uncommon and is associated with significant morbidity and mortality. It is therefore important to identify it at the earliest opportunity so that appropriate intervention can be made which protects the child from further harm. The whole topic is controversial and the aim of this paper, in question and answer format, is to review some of the more controversial areas to give an overview of the neuroimaging features of this condition. The author has drawn on his clinical and medicolegal experience of these cases, and the review is based upon questions commonly encountered in Court.

Leucodysplasia, microcephaly, cerebral malformation (LMC): a novel recessive disorder linked to 2p16.

We report three related and one unrelated child with an apparently novel neurodevelopmental disorder. The clinical course was very similar in all the four patients: congenital microcephaly with severe failure of post-natal brain growth, neonatal onset of intractable seizures associated with lack of developmental progression and death within the first 3 years of life. The appearance on cerebral neuroimaging was almost identical, with simplified gyration associated with a non-thickened cortex, severe hypoplasia of the corpus callosum, a small flattened brain stem, and specific cystic lesions in the white matter around the temporal and occipital horns. To our knowledge these patients represent a previously unreported, autosomal recessive syndrome. Homozygosity mapping in the consanguineous family has identified a candidate region on the chromosome 2p16.

Neuroradiological aspects of subdural haemorrhages.

AIMS: To review the neuroimaging of a series of infants and young children admitted to hospital with subdural haemorrhage (SDH). METHODS: Neuroradiological investigations of 74 children under 2 years of age, from South Wales and southwest England, in whom an SDH or subdural effusion had been diagnosed between 1992 and 2001, were reviewed. Two paediatric neuroradiologists blinded to the original radiological report reviewed all the relevant images. RESULTS: Neuroradiological review of images identified radiological features which were highly suggestive of non-accidental head injury (NAHI). Interhemispheric haemorrhages and SDHs in multiple sites or of different densities were almost exclusively seen in NAHI. MRI was more sensitive in identifying SDHs of different signal characteristics, posterior and middle cranial fossa bleeds, and parenchymal changes in the brain. CT scans, if performed with suboptimal protocols, were likely to miss small subdural bleeds. CONCLUSIONS: Guidelines for neuroimaging in suspected NAHI are recommended. A radiologist with experience in NAHI should report or review these scans. The initial investigation should be CT, but MRI will also be necessary in most cases. Head CT should be an integral part of the skeletal survey in all infants less than 6 months of age referred for child protection investigation, and in children less than 2 years where child abuse is suspected and there are neurological signs, retinal haemorrhages, or fractures.

Neuroimaging in non-accidental head injury: if, when, why and how.

Non-accidental head injury (NAHI) in infants is an important but difficult topic. To miss or misdiagnose NAHI potentially has important consequences. The evidence base upon which to base decisions is limited but growing. This article aims to summarise current literature and thinking in this difficult area.

Apnoea and brain swelling in non-accidental head injury.

AIMS: (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of hypoxic ischaemic brain damage, and whether this is related to a poor prognosis; and (2) to determine what degree of trauma is associated with NAHI. METHODS: Retrospective case series (1992-98) with case control analysis of 65 children under 2 years old, with an SDH secondary to NAHI. Outcome measures were presenting symptoms, associated injuries and apnoea at presentation, brain swelling or hypoxic ischaemic changes on neuroimaging, and clinical outcome (KOSCHI). RESULTS: Twenty two children had a history of apnoea at presentation to hospital. Apnoea was significantly associated with hypoxic ischaemic brain damage. Severe symptoms at presentation, apnoea, and diffuse brain swelling/hypoxic ischaemic damage were significantly associated with a poor prognosis. Eighty five per cent of cases had associated injuries consistent with a diagnosis of non-accidental injury. CONCLUSIONS: Coma at presentation, apnoea, and diffuse brain swelling or hypoxic ischaemia all predict a poor outcome in an infant who has suffered from SDH after NAHI. There is evidence of associated violence in the majority of infants with NAHI. At this point in time we do not know the minimum forces necessary to cause NAHI. It is clear however that it is never acceptable to shake a baby.

Isolated hypoglossal nerve palsy in a 14-year-old girl.

Isolated hypoglossal nerve palsy is rare, but occasionally it appears as the initial or solitary sign of an intracranial or extracranial space-occupying lesion or a vascular abnormality of the internal carotid artery. We present a 14-year-old girl who, following an upper respiratory tract infection, presented with isolated right hypoglossal nerve palsy. Anti-streptolysin O titre was increased to >1280 suggesting a preceding streptococcal infection. Magnetic resonance imaging of the brain did not show any intracranial or extracranial abnormality. She had a partial improvement at 3 months. This case emphasizes the value of recognizing the existence of benign self-limiting, post-infectious causes of isolated hypoglossal nerve palsies in children.

Magnetic resonance imaging of intraspinal cystic lesions: a pictorial review.

Magnetic resonance imaging is the imaging modality of choice for the evaluation of diseases of the spinal cord and its coverings primarily because of improved lesion detection and characterization. The differentiation of intramedullary pathologic conditions (arising within the spinal cord) from extramedullary lesions (lying either within the thecal sac (intradural) or outside it (extradural) is usually straightforward. Although many lesions may occur in more than one compartment or may extend to involve more than one compartment simultaneously, accurate positioning of a detected lesion within the spinal canal and the assessment of its signal characteristics may help differentiate many of the more commonly encountered lesions and aid preoperative diagnosis. This pictorial review discusses the imaging findings and distinguishing features of a variety of intramedullary and extramedullary intraspinal cystic lesions with the use of magnetic resonance imaging. The imaging appearances are correlated with histologic findings where available.

Administration of charcoal, Yucca schidigera, and zinc acetate to reduce malodorous flatulence in dogs.

OBJECTIVE: To determine whether feeding activated charcoal, Yucca schidigera, and zinc acetate would ameliorate the frequency and odor characteristics of flatulence in dogs. DESIGN: In vitro screening of active agents followed by a randomized controlled trial. ANIMALS: 8 adult dogs. PROCEDURE: A fecal fermentation system was used to assess the effects of activated charcoal, Yucca schidigera, and zinc acetate alone and in combination on total gas production and production of hydrogen sulfide, the primary determinant of flatus malodor in dogs. All 3 agents were subsequently incorporated into edible treats that were fed 30 minutes after the dogs ate their daily rations, and the number, frequency, and odor characteristics of flatulence were measured for 5 hours, using a device that sampled rectal gases and monitored hydrogen sulfide concentrations. RESULT: Total gas production and number and frequency of flatulence episodes were unaffected by any of the agents. Production of hydrogen sulfide in vitro was significantly reduced by charcoal, Yucca schidigera, and zinc acetate by 71, 38, and 58%, respectively, and was reduced by 86% by the combination of the 3 agents. Consumption of the 3 agents was associated with a significant decrease (86%) in the percentage of flatulence episodes with bad or unbearable odor and a proportional increase in the percentage of episodes of no or only slightly noticeable odor. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that activated charcoal, Yucca schidigera, and zinc acetate reduce malodor of flatus in dogs by altering the production or availability of hydrogen sulfide in the large intestine.

Gliomatosis cerebri in a 10-year-old girl masquerading as diffuse encephalomyelitis and spinal cord tumour.

Gliomatosis cerebri is the unifying term used when diffuse glial infiltration occurs throughout the cerebral hemispheres. The very few cases reported in children have presented with intractable epilepsy, corticospinal tract deficits, unilateral tremor, headaches, and developmental delay. Antemortem diagnosis is difficult because of the vagueness of the physical, radiological and pathological findings. Adult cases may simulate an acute diffuse encephalomyelitis and show postmortem evidence of a marked swelling of the spinal cord. Apparently benign intracranial hypertension with papilloedema has also been recorded. We report a 10-year-old girl who presented with a history and physical signs suggestive of benign intracranial hypertension. A diffuse encephalomyelopathy occurred, which was complicated by spinal cord swelling, followed by deterioration and death. Gliomatosis cerebri affecting the brain and spinal cord was found at postmortem examination.

Influence of place of delivery on outcome in babies with gastroschisis.

In order to determine whether the elective delivery of babies with gastroschisis confers advantages in outcome, the case-notes of all babies referred to Bristol with gastroschisis over a 10 year period were reviewed. Various factors were compared between babies born in Bristol and those born elsewhere in the South West region. One neonate from the outborn group died after transfer to Bristol but otherwise there was no evidence that transfer and elective delivery in Bristol conferred any advantage. The important of effective resuscitation of outborn babies before transfer is emphasised and guidelines for resuscitation given.

Feeding regimens after pyloromyotomy.

In a prospective randomized study three different feeding regimens after operation were compared in 74 babies with infantile hypertrophic pyloric stenosis: gradual regarding of feeds over 48 h (regimen 1), rapid regarding of feeds over 16 h (regimen 2), and initial starvation followed by full normal feeds at 24 h (regimen 3). No significant difference between the treatment groups was found either in episodes of vomiting after operation (regimen 1, 2.9 episodes in 21 patients; regimen 2, 3.6 episodes in 28 patients; regimen 3, 3.6 episodes in 25 patients) or in the mean duration of postoperative hospital stay (regimen 1, 59.3 h; regimen 2, 47.8 h; regimen 3, 56.7 h). We conclude that vomiting following pyloromyotomy is self-limiting and independent of the timetable or composition of the postoperative dietary regimen.