Non-accidental brain trauma in infants: diffusion imaging, contributions to understanding the injury process

doi:10.1016/j.neurad.2007.01.124

Journal of Neuroradiology

Volume 34, Issue 2, May 2007, Pages 109-114

https://doi.org/10.1016/j.neurad.2007.01.124 Get rights and content

Abstract

Analysis of MRI diffusion images from 33 infants suffering from non-accidental trauma reveals five patterns of injury. These are diffuse supratentorial hypoxic ischemic, watershed hypoxic ischemic, venous infarction, diffuse axonal injury and contusion.

Résumé

L'analyse de l'IRM de diffusion chez 33 enfants atteints de traumatisme non accidentel met en évidence cinq différents types d'atteinte cérébrale. Ils incluent des lésions hypoxo-ischémiques diffuses supratentorielles, des lésions hypoxo-ischémiques des territoires vasculaires jonctionnels, des infarctus veineux, des lésions axonales diffuses et des contusions.

Introduction

Since the introduction of diffusion-weighted imaging (DWI) in the mid-1990s as a tool in the identification of acute cytotoxic cell edema, the technique's major clinical application has been to evaluate adult stroke [9], [10] and neonatal hypoxic ischemic brain injury [1], [12]. To a lesser extent, DWI has made contributions in the characterization of central nervous system (CNS) metabolic disorders [8], certain pediatric brain tumors [4] and cerebral traumatic lesions [7].

This paper looks at the patterns of DWI abnormalities in non-accidental trauma (NAT) in infants and young children who have been the victims of abuse. This is a subject that has received relatively little attention in the literature [2], [11].

Section snippets

Materials and methods

Thirty-three infants and young children, 22 males and 11 females, ranging from 3 weeks to 4 years of age, were evaluated with MRI and DWI over a 4-year period of time. Twenty-five of 33 (76%) were 6 months or younger.

All of the patients selected for this study had an acute brain injury with a positive DWI (restricted motion of water). The 33 patients had a total of 57 CT and 40 MRI examinations during the acute phase of hospitalization following trauma. In all cases a CT preceded the MRI

Results

Five imaging patterns were found with DWI in the 33 patients with NAT. One type consisted of diffuse supratentorial brain swelling (infarction) involving the cortex and white matter of all cerebral lobes bilaterally. This was present in 13/33 (39%) (Fig. 1). The second pattern showed watershed infarction involving the parasagittal region between the anterior and middle cerebral arteries anteriorly and the posterior middle cerebral arteries posteriorly. In some cases there was also involvement

Discussion

The neuroimaging evaluation of non-accidental brain trauma in infants and young children has evolved dramatically over the last four decades from plain skull films and invasive cerebral arteriography to computed tomography (CT) and MRI. Plain films and CT continue to play an important role in identifying skull fracture as evidence of direct calvarial trauma [3]. CT and conventional MRI with T1, T2, and FLAIR, are the modalities most often utilized for the evaluation of both subdural hematomas

Conclusion

DWI, besides being sensitive to acute brain injury in non-accidental brain trauma, has been found to have patterns of injury that indicate different mechanisms by which the brain is injured.

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Cited by (55)

Imaging of Abusive Head Trauma in Children
2023, Neuroimaging Clinics of North America
Shaken baby syndrome (SBS), the challenge of reliability in the face of ignorance
2022, Bulletin de l'Academie Nationale de Medecine
La maltraitance envers les enfants a été une pratique tristement courante pendant des siècles. Dans les années 70, est individualisé le syndrome dit « du bébé secoué » (SBS) pouvant survenir sans signe extérieur de violence. Depuis, les critères diagnostiques ont pu être considérablement affinés grâce aux efforts de la communauté scientifique pédiatrique multidisciplinaire internationale, aidée par les performances croissantes des nouvelles techniques d’imagerie en coupes (scanner, IRM). Les circonstances de survenue des secouements sont maintenant connues pour être stéréotypées. Plusieurs consensus et recommandations existent dans le monde entier au sujet du diagnostic de SBS pour lequel la preuve de l’acte manque souvent. Or, malgré des efforts convergents pour reconnaitre précocement cette forme de maltraitance, un courant dénialiste actif et très largement relayé par les médias, remet en cause l’existence même du SBS notamment en France en « fabriquant de l’ignorance ». Cette revue présente le contexte, les critères médicaux diagnostiques et différentiels du SBS puis fait appel à la philosophie pour comprendre le mécanisme de l’utilisation du scepticisme à des fins stratégiques et non dans un objectif d’améliorer les connaissances. La fabrique de l’ignorance ou agnotologie consiste à rendre douteux des savoirs stabilisés en y injectant de la confusion dans un objectif d’ordre économique, politique ou social. En toute hypothèse, cette situation incite à travailler sur les relations entre la science, la médecine et la société.
Child abuse has been a sadly common practice for centuries. In the 1970s, the so-called “abusive head trauma” (AHT) was individualized and could occur without any external signs of violence. Since then, the diagnostic criteria have been considerably refined thanks to the efforts of the international multidisciplinary pediatric scientific community, helped by the increasing performance of new slice imaging techniques (CT, MRI). The circumstances in which the shaking occurred are now known to be stereotypical. Several consensus and recommendations exist worldwide regarding the diagnosis of AHT for which evidence of the act is often lacking. However, despite convergent efforts to recognize this form of mistreatment early on, an active denialist current widely relayed by the media, challenges the very existence of AHT, particularly in France, by “manufacturing ignorance”. This review presents the context, the medical diagnostic and differential criteria of AHT and then uses philosophy to understand the mechanism of using skepticism for strategic purposes and not for the purpose of improving knowledge. The manufacture of ignorance or agnotology consists in making stabilized knowledge dubious by injecting confusion into it for an economic, political or social objective. In any case, this situation encourages to work on the relationships between science, medicine and society.
Pearls and Pitfalls in Imaging of Abusive Head Trauma
2020, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
Infarcted areas will demonstrate restricted diffusion (ie, hyperintense signal on DWI and hypointense signal on apparent diffusion coefficient). The most common imaging finding is a diffuse ischemic supratentorial involvement and a watershed infarct pattern in the cerebrum.12,19 The posterior circulation territories including the brainstem, cerebellum and the thalami may be spared secondary to autoregulation.
Abusive head trauma (AHT) is the leading cause of fatal head injuries in infants. The mechanism of injury usually involves vigorous shaking of the infant, impact, or a combination of the 2. There are characteristic imaging findings of which the most common are subdural hemorrhages. Parenchymal injuries to the brain are common as well, including hypoxic ischemic injury, diffuse axonal injury, and cerebral contusions. Retinal hemorrhages are common with AHT and are best evaluated by fundoscopy, however, high grade retinal hemorrhages may be detected on cross-sectional imaging. Skull fractures are not specific to AHT but are present in third of the cases and tend to be complex in association with AHT. Injuries to the spine are more common than previously thought and typically involve soft tissues rather than bones, with the most common being ligamentous injuries in the craniocervical junction. In the setting of AHT, an affected infant would typically exhibit multiple findings. While CT of the head is the first modality of choice for assessment of an infant with AHT, magnetic resonance imaging examination of the brain and spine should follow due to its higher sensitivity for detection of these findings.
Cerebellar lesions in pediatric abusive head trauma
2019, European Journal of Paediatric Neurology
Citation Excerpt :
Cerebellar changes following shaking in AHT have only rarely been described and even less reported. In two reports on patients with AHT, three figures showed additional cerebellar lesions in 3 patients on DWI similar to the ones we found in our patients: Two cases with cerebellar involvement were reported by Zimmerman et al. 2007.14 They described five different imaging patterns on DWI in 33 infants with NAHT.
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.
The neuroimaging mimics of abusive head trauma
2019, European Journal of Paediatric Neurology
Citation Excerpt :
Subarachnoid haemorrhage as a solitary finding is non-discriminatory.25 Parenchymal contusions and diffuse axonal injury are uncommon findings in children with AHT.26 This entity is associated with various forms of delivery, both instrumented and non-instrumented.
Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the paediatric population, typically in children under the age of two years. Neuroimaging plays a key role in the diagnostic work up of these patients as information regarding the mechanism of injury is often lacking and the findings on examination can be nonspecific.
A number of conditions, both traumatic and atraumatic can mimic AHT based on neuroimaging features alone. The repercussions associated with a diagnosis or misdiagnosis of AHT can be severe and radiologists therefore need to be aware of and familiar with the imaging differentials of AHT.
In this paper we review the imaging findings of the radiological mimics of AHT and focus on features that can help differentiate these entities from AHT.
Pediatric Emergencies: Imaging of Pediatric Head Trauma
2018, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
With severe trauma, hypoxic-ischemic injury (HII) may be seen in association with extra-axial hemorrhage and is more common in the setting of AHT compared to accidental injuries (Figs. 30 and 31). Common imaging patterns of HII include diffuse ischemic injury, watershed distribution injury, and, less commonly, focal injury or venous infarction.26 Often the amount of subdural hemorrhage is small in relation to the extent of HII, but may serve as a potential marker of trauma.
Pediatric head trauma is an important cause of morbidity and mortality in children and may be seen in the setting of accidental or abusive injuries. Although many of the patterns of head injury are similar to adults, the imaging manifestations of head injury in children are more complex due to the developing brain and calvarium. Additionally, there are unique considerations for mechanisms of injury in children, to include abusive head trauma and birth-related injuries. The primary role of the radiologist is to identify and characterize the type and severity of head injury to help guide appropriate patient management.

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Original articleNon-accidental brain trauma in infants: diffusion imaging, contributions to understanding the injury processTraumatismes non accidentels du nourrisson : imagerie de diffusion, contributions dans la compréhension des mécanismes

Abstract

Résumé

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Am. J. Ophthalmol.

Proton spectroscopy and diffusion imaging on the first day of life after perinatal asphyxia: preliminary report

Am. J. Neuroradiol.

Nonaccidental head injury in infants—the shaken-baby syndrome

N. Engl. J. Med.

Diffusion-weighted imaging and fluid attenuated inversion recovery imaging in the evaluation of primitive neuroectodermal tumors

Neuroradiology

Acute diffusion abnormalities in the hippocampus of children with new-onset seizures: the development of mesial temporal sclerosis

Neuroradiology

Neuropathology of inflicted head injury in children. I. Patterns of brain injury

Brain

Original article
Non-accidental brain trauma in infants: diffusion imaging, contributions to understanding the injury processTraumatismes non accidentels du nourrisson : imagerie de diffusion, contributions dans la compréhension des mécanismes