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Pediatric abusive head trauma: visual outcomes, evoked potentials, diffusion tensor imaging, and relationships to
John P Kelly1,2, Kenneth W Feldman3,4, Jason N Wright5
1Roger H. Johnson Vision Clinic, Division of Ophthalmology, Seattle Children's Hospital, Seattle, WA, 98105, USA. john.kelly@seattlechildrens.org.
Insights
Abusive head trauma (AHT) in children can cause lasting visual pathway damage, particularly with macular abnormalities. Visual evoked potentials (VEPs) better detect this dysfunction than visual acuity or diffusion tensor imaging (DTI).
Area of Science:
- Ophthalmology and Neuroscience
- Pediatric Traumatology
Background:
- Abusive head trauma (AHT) is a severe form of child abuse with significant neurological consequences.
- Visual system impairment is a common, yet often underdiagnosed, sequela of AHT.
Purpose of the Study:
- To evaluate the function and anatomy of the visual system in children with AHT.
- To examine the relationship between retinal hemorrhages at presentation and long-term visual outcomes.
Main Methods:
- Retrospective review of 45 children diagnosed with AHT.
- Assessment of visual acuity (logMAR), visual evoked potentials (VEPs), and diffusion tensor imaging (DTI) metrics of the occipital lobe.
- Analysis of retinal hemorrhage patterns at initial presentation.
Main Results:
- Reduced visual acuity (median logMAR 0.8) and absent VEP signals (32%) were observed in AHT survivors.
- VEPs were significantly reduced in patients with traumatic retinoschisis or macular hemorrhages (p < 0.01).
- DTI metrics showed decreased white and grey matter volumes in AHT subjects, correlating with macular abnormalities but not visual acuity or VEPs.
Conclusions:
- Mechanisms causing traumatic retinoschisis and macular abnormalities are linked to persistent visual pathway dysfunction.
- Visual evoked potentials (VEPs) provide a more comprehensive assessment of AHT-related visual pathway dysfunction than visual acuity or DTI.
Purpose:
Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures.
Methods:
Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR).
Results:
Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping.
Discussion:
Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics.
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