Cerebellar lesions in pediatric abusive head trauma

Highlights

• There is an additional cerebellar involvement in cases of severe pediatric abusive head trauma.

• In the acute phase the cerebellar pathology is characterized by bilateral diffusion changes of the cerebellar hemispheres.

• On follow-up cortico-subcortical signal alterations appear in the depth of the foliae most prominent on T2weighted images.

Abstract

Pediatric abusive head trauma (AHT) or non accidental head trauma (NAHT) is a major cause of death from trauma in children under 2 years of age. Main etiological factor for non accidental head trauma is shaking a baby, causing brain injury by rotational head acceleration and deceleration. The consequent brain damage as shown by magnetic resonance imaging (MRI) is subdural haemorrhage and to a lesser extent parenchymal injuries of variable severity. Involvement of the cerebellum has very rarely been described.

We report the clinical history and the development of cerebral magnetic resonance imaging findings in two children with serious brain injury following probable shaking who presented the typical “triad” with subdural haematoma, retinal haemorrhage and encephalopathy. We want to draw attention to cerebellar involvement characterized by cortico-subcortical signal alterations most prominent on T2w images following diffusion changes during the acute period. We discuss cerebellar involvement as a sign of higher severity of AHT which is probably underrecognized.

Introduction

The current definition of pediatric abusive head trauma (AHT) includes an injury of the skull/intracranial contents of a child up to the age of five years due to intentional abrupt impact and/or violent shaking.¹ This term is accepted for the intracranial and spinal lesions in abused infants and children.² NAHT (non accidental head trauma) is often used synonymously. Shaking is supposed to be the main mechanism of death from AHT in babies between three and six months.3, 4 In Western countries the incidence of AHT in children under one year ranges from 14 to 28 per 100.000 live-births and AHT represents the major cause of head injury in children under one year.5, 6

AHT is characterized by a triad of subdural haematoma, retinal haemorrhages and encephalopathy.3, 4, 7 Additionally there is a high incidence of cervical spine injury.⁸ AHT can be caused by shaking alone. External signs of injury are often missing and symptoms can be nonspecific and similar to viral infection or minor illness. Only severe cases show life-threatening symptoms.2, 9, 10, 11

The consequent brain damage as revealed by magnetic resonance imaging (MRI) is well described mainly consisting in subdural haemorrhage and subsequent development of hygroma. To a lesser extent reports refer to cerebral parenchymal injuries. And to our knowledge to date MRI findings showing involvement of the cerebellum in AHT have very rarely been reported and not specially described with respect to follow-up.

In many cases, the crucial factor for the outcome of affected children is not the subdural and/or subarachnoidal bleeding but the subsequent effects and severity of the intraparenchymal injuries.²

We report two cases of children with AHT and present their clinical history and the evolution of their severe brain lesions as seen by MRI and draw attention to the associated cerebellar lesions. We collect evidence that additional cerebellar lesions in AHT indicate a higher severity of the brain damage.