Child Abuse – Nonaccidental Injury (nai)

Conclusion
An extensive review of the literature to date fails to establish an evidence base for reliably distinguishing NAI from AI or from the medical mimics. The medical and imaging findings alone cannot diagnose “intentional” injury. Only the child protection investigation may provide the basis for “inflicted” injury in the context of “supportive” medical, imaging, or pathologic data. The duty of the radiologist is to give a detailed description of the imaging findings, provide a differential diagnosis, and communicate the concern for NAI, directly to the primary care team in a timely manner. The radiologist should be prepared to consult with child protection services, other medical and surgical consultants, including the pathologist or biomechanical specialist, law enforcement investigators, and attorneys for all parties as appropriate. The radiologist must also be aware of certain conditions that are known to have clinical and imaging features that may mimic abuse. These should be properly evaluated, and the possibility of combined, or multifactorial, mechanisms with synergistic effects should also be considered. Furthermore, a negative medical evaluation does not make NAI the default diagnosis. A timely and thorough multidisciplinary evaluation may be the difference between appropriate child protection versus an improper breakup of the family or a wrongful indictment and conviction.
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Table 2 - MRI of Intracranial Hemorrhage & Thrombosis*


STAGE BIOCHEMICAL FORM SITE T1-MRI T2-MRI

Hyperacute Fe II oxyHb Intact RBCs Iso-Low I High I

(+edema)

[<12 hours]

Acute Fe II deoxy Hb Intact RBCs Iso-Low I Low I

(+edema)

[1-3 days]
Early Subacute Fe III metHb Intact RBCs High I Low I

(+edema)

[3-7 days]
Late Subacute Fe III metHb Lysed RBCs High I High I

(-edema) (extracellular)

[1-2 weeks]
Early Chronic Fe III transferrin Extracellular High I High I

(-edema)

[>2 weeks]
Chronic Fe III ferritin & Phagocytosis Iso-Low I Low I

(cavity) hemosiderin

*RBCs - red blood cells, I - signal intensity, + present, - absent, Hb - hemoglobin, Fe II - ferrous, Fe III - Ferric, Iso - isointense.
Barkovich A. Pediatric Neuroimaging, 4^th edition, Philadelphia, Lippincott-Raven, 2005, 190-290.
Zuerrer M, Martin E, Boltshauser E. MRI of intracranial hemorrhage in neonates and infants at 2.35 Tesla. Neuroradiology 1991;33:223-229
Barnes P, Krasnokutsky M. Imaging of the CNS in suspected or alleged nonaccidental injury, including the mimics. Top Magn Reson Imaging 2007;18 (1): 53-74.