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KEY FACTS

Terminology
- Abusive head trauma (AHT)
- Traumatic injury inflicted on infants & children by adults
Imaging
- Direct impact injury: Direct blow to cranium - Calvarial (often complex) & skull base fractures - Focal brain injury deep to impact
- Shaking injury: Result of violent to-&-fro motion of head - Subdural hematomas (SDHs) in 90-98% - Generalized parenchymal injuries (cytotoxic edema, lacerations, axonal injury) - Bridging vein injury & thrombosis common
- CT primary imaging tool in initial evaluation of AHT - Multiplanar reconstructions improve detection of - Small intracranial hemorrhages (ICHs) - Fractures (with bone algorithm & 3D reformats)
- MR best for determining full extent of injury - DWI paramount for parenchymal injury - SWI/T2* GRE for hemorrhage - T2/T1/FLAIR for detection of subdural collections - T1 C+ for chronic SDH membranes
- Avoid speculation regarding timing & specific source of injury in report
Top Differential Diagnoses
- Accidental trauma
- Benign macrocrania of infancy
- Mitochondrial encephalopathies
- Bleeding disorders
Clinical Issues
- Discordance between stated history & degree of injury - "Killer couch": Injuries blamed on infant rolling off couch
- Retinal hemorrhages in ~ 75%
- #1 cause of brain injury death in children < 2 years of age - 17-25:100,000 annual incidence - Cause of death in 80% of fatalities is brain swelling - Severe hypoxic ischemic encephalopathy > diffuse axonal injury
Diagnostic Checklist
- Reporting tips - Avoid temptation to precisely time ICH - Avoid vague, oblique, obscuring language in reports - Avoid speculation regarding source of injury

TERMINOLOGY

Abbreviations
- Abusive head trauma (AHT)
Synonyms
- Battered child syndrome, whiplash shaken infant syndrome, trauma-X, Caffey-Kempe syndrome, shaken-baby syndrome, nonaccidental head injury
- Multiple alternate titles have been suggested in attempt to minimize accusatory labeling in clinical setting - May do more harm than good by causing confusion & hampering communication
Definitions
- Traumatic injury inflicted on infants & children by adults - This discussion centers on head injury

IMAGING

General Features
- Multiple brain injuries disproportionately severe relative to offered history
- 2 major groupings of injuries (but can occur together) - Direct impact injury: Result of direct blow to cranium or impact of skull on object - Shaking injury: Result of violent to-&-fro head motion
- Direct impact injury typified by skull fractures & injury to immediately underlying brain - Scalp laceration, hematoma, swelling strongly associated - High association with injuries to other organs
- Shaking injury typified by subdural hemorrhage (SDH) & generalized brain parenchymal injury - Cytotoxic brain injury not conforming to arterial territories - Exact etiology of parenchymal injury uncertain but usually permanent - Hypoxic-ischemic vs. direct traumatic brain injury - May see bridging vein injury ± thrombosis - Imaging findings may suggest injuries of differing ages
Radiographic Findings
- Sensitive in detection of linear skull fractures - Fracture detection key component in forensic evaluation of suspected nonaccidental trauma (NAT) - CT (with appropriate techniques) better characterizes fractures; often being obtained to evaluate for intracranial hemorrhage (ICH)
- Some fractures considered more suspicious for NAT - Evidence does not support this - Multiple compound, diastatic fractures, & fractures crossing sutures imply significant trauma but are not specific for NAT - Discordance with provided history best indicator
CT Findings
- NECT primary imaging tool for initial evaluation of AHT
- ICH - SDH most common (90-98%) - Dominant feature of shaking injury - Overlying cerebral convexities, in interhemispheric fissure, overlying tentorium - Normal density of subarachnoid space (SAS) stands out next to ↑ density of SDH - Subarachnoid hemorrhage common (> 50%) - Epidural hemorrhage uncommon but may occur - More characteristic of accidental trauma - Use great caution if attempting to estimate "age" of ICH - Blood density based upon multiple factors: CSF dilution, hematocrit, coagulation status - SDHs of same age can have significantly different densities - Acute SDHs likely to have hyperdense component but usually have associated low-attenuation component from CSF admixture (i.e., hematohygroma) - Most specific findings for chronic SDHs are compartmentalization/loculation & membrane formation
- Bridging vein injury ± thrombosis common (40-50%) - Areas of ↑ density in paramedian high convexities - Tadpole & lollipop signs - May occur in accidental injury but more common in AHT
- Parenchymal ischemic injury often seen in shaking injuries - Areas of ↓ density (with loss of gray matter-white matter differentiation) & sulcal effacement not confined to arterial territories; may be diffuse - ↓ density of cerebrum vs. cerebellum: "Bright cerebellum" - May be evident within several hours after injury
- Parenchymal laceration in 10-15% - More commonly seen in AHT vs. accidental injury
- Shear injury (axonal injury) in ~ 15%
- Retinal hemorrhages uncommonly visualized on CT
- CECT: Enhancing membranes best sign of chronic SDH
- CTA: Detectable vascular injury relatively uncommon in child abuse - Posttraumatic aneurysm, dissection can be demonstrated by CTA
MR Findings
- DWI: Key for parenchymal injury - Patterns of parenchymal injury are variable, including diffuse symmetric, multifocal, & focal
- T1WI: Bright foci of hemorrhage or evolving cortical injury
- T2WI: Loss of cortical ribbon & deep nuclei in neonates - Coronal T2 often helpful to identify bridging vein injury - Lacerations are characterized by fluid clefts with hematocrit levels
- FLAIR: Very sensitive for detection of small subdural collections
- SWI/T2 GRE*: Detects small ICH ± retinal hemorrhages - SWI is ~ 50% sensitive & 100% specific for retinal hemorrhage - Best sequence for detecting & characterizing bridging vein injury
- T1WI C+: Enhancing membranes best sign of chronic SDH
- MRA: Proximal vascular correlate (dissection, spasm) rarely shown in association with parenchymal injury
- MRS: Will show ↓ NAA, ↑ lactate in regions of parenchymal injury; may detect injury in normal-appearing regions

Imaging Recommendations

Best imaging tool

- NECT for acute evaluation
        - Sensitive in detection & characterization of fractures
        - Sensitive in detection & characterization of most ICH, but small low attenuation subdurals can be missed
- MR after 48-72 hours
        - Best exam for characterizing brain injury
        - Helpful to further characterize subdural collections (CT & MR are complementary)

Protocol advice

- NECT: Multiplanar & 3D reconstructions improve detection of
        - Small ICHs
        - Fractures (especially with bone algorithm & 3D)
        - Consider imaging down to C2 to detect atlantooccipital injuries
- MR: DWI to assess parenchymal injury; FLAIR/SWI sequence to detect subtle SDH/subdural hygroma
- MRA or CTA to evaluate suspected pseudoaneurysm or dissection

DIFFERENTIAL DIAGNOSIS

Accidental Trauma
- Appropriate history for degree of injury
Benign Macrocrania of Infancy
- Self-limited communicating hydrocephalus
- Prominence of extraaxial spaces → isodense to CSF
Mitochondrial Encephalopathies
- May cause atrophy with subdural collections - Glutaric acidurias (types I & II), Menkes syndrome - Rare diseases with preexisting neurologic symptoms
Overshunting
- "Passive" subdurals can develop from ↓ volume associated with CSF shunting
Subdural Empyema
- Febrile, sinusitis, meningitis
Bleeding Disorders
- von Willebrand, thrombocytopenia
- Intracranial bleeding with minor trauma

PATHOLOGY

General Features
- ↑ vulnerability in infants due to - Large head:body ratio + weak neck muscles - Developing brain has less structural integrity prior to myelination, greater susceptibility to injury
- 85% of fatal child abuse victims have evidence of impact head injury at postmortem examination
- Retinal hemorrhage in ~ 75% (50-100% in literature) - Much less common in accidental head trauma (~ 6%)
- Retroclival collections can be seen in ~ 30% of AHT victims

CLINICAL ISSUES

Presentation

Most common signs/symptoms

- Discordance between stated history & degree of injury
        - Attempt by perpetrator to minimize suspicion
        - "Killer couch": Severe injuries blamed on infant rolling off couch onto floor by perpetrator
                  - Frequently in infants too young to roll over at all
- Unprovoked seizures & apnea raise suspicion for AHT

Other signs/symptoms

- Poor feeding, vomiting, irritability, seizures, lethargy, coma, apnea
- Retinal hemorrhage
        - Can be missed on cursory exam
        - Can be seen in glutaric acidurias
- Cause of death in 80% of fatalities is brain swelling
        - Severe hypoxic ischemic encephalopathy > diffuse axonal injury

Clinical profile

- Perpetrators are often direct caretakers: Parents, babysitters, mother's boyfriend
- Developmentally delayed, "colicky," premature or low-birth-weight infants at higher risk
- Psychosocial stressors & poor coping mechanisms in family environment

Demographics
- Most common from 1-6 months of age
- 17-25:100,000 annual incidence - Almost certainly underreported - #1 cause of brain injury death in children < 2 years of age
- M > F
Natural History & Prognosis
- Mortality rate: 20-25%
- High rates of impairment for survivors - Psychomotor delay, epilepsy, visual impairment, cognitive/behavioral disorders
Treatment
- Notification of local Child Protection Agency - Mandated in USA/Canada/Australia/some European countries
- Multidisciplinary child abuse & neglect team intervention

DIAGNOSTIC CHECKLIST

Image Interpretation Pearls
- Avoid temptation to precisely time ICH
- Accurate descriptions & detailed report are most helpful
Reporting Tips
- Avoid use of vague, oblique, obscuring language in reports - Can hamper care of child & legal investigation - May ↑ likelihood of interpretation being challenged in legal proceedings
- Avoid speculation regarding timing & specific source of injury in report - Appropriate to raise concern for abusive head injury - More can always be said about timing & mechanism in legal setting, but once statement is made in report, it is difficult to retract

cf586261-2109-4438-b175-9f1754ef6b56

References

Selected References

Differential diagnosis

Macrocrania/Macrocephaly

DDX:f2d6806c-a267-4f64-ba16-b0fa89e229b6

Microcephaly

DDX:6083739e-ec7b-48ad-9b34-80434c3142f2

Microcephaly

DDX:17ae265f-b471-4ca0-bba4-75b73a9d76f6

Ventriculomegaly

DDX:da3780c6-b627-47c3-912d-6f4c452a1acd

Anatomy

Visual Network

Brain/ANATOMY:404625d9-3125-4923-9f9d-53d0f81c3542

Embryology and Anatomy of the Brain

Obstetrics/ANATOMY:bf20450d-2629-4795-98e7-7788b665ad3c

Embryology and Anatomy of Brain

Ultrasound/ANATOMY:8fb2f541-799d-479f-b000-ab54f216199a

Cases

{'cases': [{'authors': [{'key': '838e1722-2479-4fbd-a5fe-d965980a1a2c', 'value': 'Blaise V. Jones, MD'}], 'caseVersionId': 'fade88d5-75e7-42b2-8495-32157314e199', 'description': "Initial CT images (#1, 2) show loss of gray-white differentiation and swelling throughout the right cerebral hemisphere, along with subdural blood (arrows, #1,2). No fractures were identified. \n\nFollow-up CT study less than 24 hours later (#3) showed progression of right hemisphere swelling, with transtentorial, subfalcine, and uncal herniation. Gray-white differentiation is accentuated on this exam, but in an inverted configuration, with the white matter being more dense than the edematous gray matter. This is in contrast to the normal relationship demonstrated in the left hemisphere. This is the "reversal sign", indicating a severe and irreversible insult.\n\n"Killer couch" is a term sardonically used by health care professionals in reference to the frequent explanation of the injury leading an abused infant to medical care. The child is frequently said to have rolled off a sofa onto a carpeted or wooden floor, typically unwitnessed. The abuser's attempt to minimize the trauma is often the first clue to the correct diagnosis of inflicted injury, as it is so disproportionate to the documented degree of injury.", 'history': 'Fell off a sofa. Now unresponsive.', 'imagePoolId': 'dafd3e2b-c935-4e57-bc98-7d7273efa5ac', 'name': 'Killer couch, reversal sign', 'teachingPoint': None, 'demographics': '18 Months old female'}, {'authors': [{'key': '815f3e98-b5da-43c7-8f99-d3db52947320', 'value': 'Hank Baskin, MD'}], 'caseVersionId': '224f3ea3-1e84-4150-a090-b28e8e096129', 'description': 'Axial NECT images (#1-3) show abundant extraaxial hemorrhage (straight arrows) scattered over the bilateral hemispheres and within the interhemispheric fissure. There is also diffuse low attenuation of the cerebral hemispheres from generalized cerebral edema (black open arrows) which, juxtaposed by the more normal attenuation cerebellum (white open arrows, #1), creates the "CT reversal sign." Edema also causes effacement of the lateral ventricles (white curved arrows, #2) and perimesencephalic cisterns (black curved arrow, #2).', 'history': 'Patient was brought to emergency department because of seizure and listlessness; there is generalized cerebral edema and diffuse extraaxial hemorrhage from abusive head trauma; the child died 24 hours later.', 'imagePoolId': '00693687-d787-4c62-b446-88c55fe71d0d', 'name': 'Diffuse cerebral edema blood CT brain death', 'teachingPoint': None, 'demographics': '7 Weeks old male'}, {'authors': [{'key': '838e1722-2479-4fbd-a5fe-d965980a1a2c', 'value': 'Blaise V. Jones, MD'}], 'caseVersionId': '11b1d3de-688f-46d6-8eed-929c48dde54d', 'description': 'This case illustrates the CT and MR appearance of subacute to chronic subdural hematomas due to child abuse.\n\nInitial CT image (#1) shows subdural collections over both frontal lobes that are higher in attenuation that the underlying CSF in the subarachnoid space (arrows). This is further illustrated by the signal difference in the subdural collections on proton-density T2WI (#2) from an MR obtained the next day. Note the hyperintense signal in the subdural space posteriorly on T1WI and the hyperintense hemorrhagic staining in the left parietal cortex and T1WI (arrows, #3, 4). It is tempting to interpret these findings as reflecting more acute blood posteriorly and chronic subdurals anteriorly, but this is just as likely to represent pooling of blood products posteriorly such that the anterior portions of the collections only have xanthochromic CSF.\n\nDWI and ADC maps (#5, 6) show that there is significant injury to the posterior parietal and occipital lobes. \n\nMR is invaluable in showing the extent of brain injury in cases of child abuse.', 'history': '"Fell out of bed."', 'imagePoolId': '7d55e0da-c1df-4bd9-9be6-c9b0973a098a', 'name': 'Subdurals', 'teachingPoint': None, 'demographics': '3 Months old '}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '4e001e30-c901-4297-9ce6-e2406f4aceaa', 'description': 'MR can be very helpful in detecting mixed-age subdural hematomas. Here axial T1 weighted MR scans (#1-2) show high signal intensity extra-axial fluid over the right hemisphere. There is a hypointense collection on the left that may represent expanded subarachnoid space. T2 weighted scans (#3-4) show the right subdural collection is mostly hyperintense, but the more posterior portion (curved arrows) appears hypointense, indicated more recent hemorrhage. Other scattered foci of recent hemorrhage (open arrows) can be seen. At least two separate episodes of hemorrhage are present. Note scalp swelling (#4).', 'history': '"Fell off the couch." Nonaccidental trauma suspected.', 'imagePoolId': '4f28cfd1-8a22-4de3-a92b-469a0622f620', 'name': 'Classic mixed-age SDHs', 'teachingPoint': None, 'demographics': '3 Months old female'}, {'authors': [{'key': '5cff4116-3654-4b3a-bb75-5ebe0b8c9850', 'value': 'Anne G. Osborn, MD, FACR'}], 'caseVersionId': '957a51bc-7a33-4558-9358-8cc3767a3392', 'description': 'Axial NECT scans show bifrontal low density extra-axial fluid collections (arrows). Note evidence for more recent, higher density hemorrhage (curved arrows) within the hypodense subdurals (SDHs). The more chronic, low density SDH extends along the interhemispheric fissure (open arrows). The presence of mixed-age SDHs, together with interhemispheric extension, strongly suggests nonaccidental trauma.', 'history': 'Suspected "shaken baby" syndrome.', 'imagePoolId': 'bc6acdb7-8626-404f-9894-1f693635b865', 'name': 'Mixed SDHs', 'teachingPoint': None}, {'authors': [{'key': 'e8af6d26-3aad-47c9-9083-5128aab09af2', 'value': 'Susan I. Blaser, MD, FRCPC'}], 'caseVersionId': 'd11c767b-2d5b-4a35-80d5-c8cf7739b3a2', 'description': 'Rib series demonstrates multiple healing rib fractures (#1). NECT obtained after fractures found (#2) demonstrates large subdural fluid collection (arrow), diffuse hypodensity of brain substance and significant shift of midline structures. Note thin interhemispheric subdural bleed (curved arrows). Nuclear brain perfusion study (#3) demonstrates total lack of cerebral or cerebellar perfusion. Nonaccidental trauma remains the most common cause of traumatic infant death.', 'history': 'Found in coma several days after minor fall.', 'imagePoolId': 'be0460c7-7fa9-46a3-bda9-e0736f3140eb', 'name': 'Severe', 'teachingPoint': None, 'demographics': '4 Months old female'}, {'authors': [{'key': 'c313fa7b-5bff-4b39-a8cd-dcf06aa6a69d', 'value': 'A. Carlson Merrow, Jr., MD, FAAP'}], 'caseVersionId': 'f3b8d15f-f11a-493f-9eba-f1e4effcbe6a', 'description': 'Axial NECT images of the brain (#1-2) show a mixed hyper- and hypodense subdural collection overlying the right cerebral convexity (straight black arrows). There is generalized sulcal effacement (open white arrow) as compared to normal left cerebral sulci (curved white arrow, #1). Note that the right lateral ventricle is completely effaced (curved black arrow, #1). There is moderate to marked leftward midline shift (straight white arrow, #2). Axial T2WI (#3) and FLAIR (#4) MR images obtained 3 days later (after craniotomy) show right cerebral edema with increased cortical/subcortical signal and gyral swelling/sulcal effacement (open white arrows). A tiny subdural hematoma (straight white arrow) remains. Note the largely normal left cerebral hemisphere (open black arrow). On axial DWI MR (#5), there is restricted diffusion of the entire right cerebral hemisphere (curved arrow), confirmed on the ADC map (curved arrow, #6). This patient suffered child abuse with an extensive right cerebral injury and subdural hematoma.', 'history': 'Patient not moving left arm.', 'imagePoolId': '0800593d-f847-40e5-b1f9-4aa3221e2027', 'name': 'Subdural, infarction', 'teachingPoint': None, 'demographics': '12 Months old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
{'cases': [{'authors': [{'key': '838e1722-2479-4fbd-a5fe-d965980a1a2c', 'value': 'Blaise V. Jones, MD'}], 'caseVersionId': '3f0a013a-e4a5-4bca-be4b-6340362e688e', 'description': 'This case illustrates an unusual complication of child abuse; an aneurysm of the anterior cerebral artery (pericallosal artery).\n\nNote the small focus of high attenuation in the interhemispheric fissure anteriorly (curved arrow, #2) in this child who presented after abusive head injury causing multiple extra-axial hemorrhages (#1). Follow-up CT (#3, 4) shows the development of post-traumatic hydrocephalus and a calcified mass at the site of the prior density (arrow, #4). \n\nCTA (#5, 6) shows that this is a partially calcified aneurysm (arrows), confirmed on arteriography (curved arrow, # 7) to be at the junction of the pericallosal and callosal-marginal arteries. The aneurysm was coiled (curved arrow, #8) and sagittal MR before (#9) and after (#10) show elimination of the aneurysm (curved arrow, #10).', 'history': "Beaten by mother's boyfriend.", 'imagePoolId': 'a600d880-39df-4121-80a5-51d3925f66d2', 'name': 'Aneurysm', 'teachingPoint': None, 'demographics': '4 Months old male'}], 'caseType': 'variant', 'name': 'VARIANT'}

Images

Selected Images

Axial NECT in a 9-week-old with seizures shows bilateral mixed attenuation subdural fluid collections with predominantly low attenuation anteriorly & high attenuation posteriorly , consistent with a hematohygroma. This should not be described as "acute on chronic" subdural hemorrhage.

Coronal NECT in the same patient shows the bilateral subdural collections as well as globular areas of hemorrhage in the parasagittal regions, consistent with bridging vein injuries/avulsions.

Axial DWI MR in the same patient performed 3 days after presentation shows asymmetric (right > left) diffusion restriction , consistent with brain parenchymal injury. MR is the best exam for detection & characterization of brain injury in accidental head trauma.

Coronal SSFSE in the same patient 6 weeks later shows a membrane separating loculated hyperintense & hypointense subdural components, a finding that suggests some component of chronicity.

Axial DWI MR in a 2-month-old with unexplained altered mental status & seizure shows nearly symmetric diffusion restriction in the bilateral parietooccipital regions.

Axial T2 MR in the same patient shows bilateral clefts with hematocrit levels, consistent with lacerations . Also note the bilateral subdural hemorrhages . This constellation of parenchymal injury, brain lacerations, & bilateral subdural hemorrhages is highly suspicious for abusive head trauma (AHT).

Axial NECT in a 6-week-old with AHT shows hypodense subdural collections & left frontal arachnoid hemorrhage . ↓ attenuation throughout the cerebrum with loss of gray matter-white matter differentiation is consistent with injury. Compare to the normal cerebellum .

Axial SWI in a 3-month-old with AHT shows thin areas of ↓ signal , consistent with bilateral retinal hemorrhages. MR is insensitive for detection of retinal hemorrhages, but they should be reported when present.

Axial NECT in a 2-month-old with AHT shows subdural hemorrhage over the left frontal lobe & along the falx. Note the extensive areas of ↓ attenuation & loss of gray matter-white matter differentiation with significant left-to-right midline shift.

Coronal FLAIR MR in the same patient 7 years later shows development of extensive areas of cystic & noncystic encephalomalacia affecting the left > right cerebral hemispheres.

Additional Images

$Posterior oblique view of a 3D NECT in a 9-week-old who "fell off the couch" shows multiple complex skull fractures , including a displaced right parietal fracture . 3D renderings are helpful in improving the detection & characterization of skull fractures.$ Posterior oblique view of a 3D NECT in a 9-week-old who "fell off the couch" shows multiple complex skull fractures , including a displaced right parietal fracture . 3D renderings are helpful in improving the detection & characterization of skull fractures.

Axial NECT in the same 9-week-old shows a right subdural hematoma (SDH) & right opercular parenchymal laceration with significant midline shift & sulcal effacement. Parenchymal lacerations are seen in 10-15% of AHT patients.

$Axial NECT in a 4-month-old boy with seizure activity shows multiple bilateral foci of low attenuation with loss of cortical differentiation as well as a left frontal SDH . There was no fracture, making these findings highly concerning for the shaking type of AHT.$ Axial NECT in a 4-month-old boy with seizure activity shows multiple bilateral foci of low attenuation with loss of cortical differentiation as well as a left frontal SDH . There was no fracture, making these findings highly concerning for the shaking type of AHT.

Axial DWI MR in a 2-month-old boy with AHT shows areas of diffusion restriction in the right frontal lobe & bilateral parietal lobes, consistent with parenchymal injury. MR is the most sensitive examination for parenchymal injury.

Coronal NECT in a 3-month-old with ABT shows focal areas of parasagittal hemorrhage . The lesion on the left has a lollipop or pollywog appearance, typical for cortical vein avulsion, a finding that is fairly specific for AHT.

Initial coronal NECT in a 1-month-old girl with AHT shows bilateral paramedian extraaxial hemorrhages , a characteristic finding in AHT attributed to bridging vein injury & thrombosis. In all, 40-50% of AHT cases show evidence of bridging vein injury.

Axial SWI in a 6-week-old shows subdural & subarachnoid hemorrhage as well as an evolving left frontal lobe laceration with hemorrhage level, a constellation of findings very suspicious of AHT.

Axial T2 SWI MR in a 4-month-old with AHT shows bilateral retinal hemorrhages . Although SWI is the most sensitive imaging sequence for retinal hemorrhages, it is insensitive relative to a funduscopic exam. A normal MR appearance of the globes does not exclude retinal hemorrhages.

Initial axial NECT in the same patient shows SDH layering along the left tentorium with a slight ↑ in bifrontal hypodense extraaxial spaces .

Axial NECT in the same patient 3 days later shows more conspicuous layering of a SDH in the posterior fossa. Also note the significant enlargement of the low-attenuation extraaxial collections , most of which are nonhemorrhagic & isodense to CSF, consistent with enlarging subdural hygromas (SDHy). As illustrated by this case, it is impossible to say that a predominantly nonhemorrhagic collection with a small amount of acute SDH is an "acute-on-chronic" SDH. Rather, when such an appearance is encountered on initial imaging, it is more likely an acute mixed SDH/SDHy.

Axial T2WI in the same 1-month-old girl with AHT on day 2 shows significant enlargement of the extraaxial collections , most of which is nonhemorrhagic & isointense to CSF, consistent with a growing SDHy.

Axial PD MR shows bilateral SDHs after a shaking injury. Note how this sequence clearly differentiates between the subdural collections & the underlying subarachnoid space .

Axial DWI MR in the same patient shows a small focus of parenchymal diffusion restriction in the left anterior operculum, consistent with parenchymal injury, which was not evident on CT. MR is the most sensitive test for parenchymal injury in the setting of AHT.

Axial NECT in a 6-month-old girl with AHT shows high attenuation in the posterior right globe, consistent with retinal hemorrhage. Retinal hemorrhage is rarely seen on CT but strongly suggests nonaccidental trauma (NAT).

$Lateral radiograph shows multiple fractures that cross sutures & are diastatic. There is also coronal suture diastasis .$ Lateral radiograph shows multiple fractures that cross sutures & are diastatic. There is also coronal suture diastasis .

$Axial NECT in a 3-month-old presenting with skull fractures shows subdural blood overlying most of the right cerebral hemisphere & exerting mild mass effect on the underlying brain. Blood on either side of the sagittal sinus gives rise to the empty delta sign , a mimic of sinus thrombosis.$ Axial NECT in a 3-month-old presenting with skull fractures shows subdural blood overlying most of the right cerebral hemisphere & exerting mild mass effect on the underlying brain. Blood on either side of the sagittal sinus gives rise to the empty delta sign , a mimic of sinus thrombosis.

Coronal T2 MR in a 2-month-old presenting to the emergency department unresponsive shows regions of hyperintensity with loss of gray matter-white matter differentiation in the left temporal lobe & parasagittal regions . Hypointense signal in the right parasagittal cortex reflects hemorrhagic staining.

Coronal T2 MR in the same child 9 months later shows focal volume loss in both areas of injury , with associated enlargement of the ventricles & interhemispheric fissure.

Lateral catheter DSA in an infant with AHT shows a posttraumatic pseudoaneurysm at the junction of the pericallosal & callosal-marginal arteries .

Axial PD MR shows a SDH over the left cerebral hemisphere. Although blood along the falx would be seen, the small volume laterally could be difficult to detect on CT.

Axial NECT shows generally poor gray matter-white differentiation & subdural blood along the tentorium in a 5-month-old with a shaking-induced injury.

Axial NECT in the same child 12 hours later shows the rapid development of multiple regions of cytotoxic edema with effacement of the 3rd ventricle & cisterns.

57 KiB Raw Blame History Unescape Escape

KEY FACTS

Terminology

Imaging

Top Differential Diagnoses

Clinical Issues

Diagnostic Checklist

TERMINOLOGY

Abbreviations

Synonyms

Definitions

IMAGING

General Features

Radiographic Findings

CT Findings

MR Findings

Imaging Recommendations

Best imaging tool

Protocol advice

DIFFERENTIAL DIAGNOSIS

Accidental Trauma

Bleeding Disorders

PATHOLOGY

General Features

CLINICAL ISSUES

Presentation

Most common signs/symptoms

Other signs/symptoms

Clinical profile

Demographics

Natural History & Prognosis

Treatment

DIAGNOSTIC CHECKLIST

Image Interpretation Pearls

Reporting Tips

References

Selected References

Differential diagnosis

Macrocrania/Macrocephaly

Microcephaly

Microcephaly

Ventriculomegaly

Anatomy

Visual Network

Embryology and Anatomy of the Brain

Embryology and Anatomy of Brain

Cases

Images

Selected Images

Additional Images

57 KiB

Raw Blame History