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Neuroimaging of nonaccidental head trauma: pitfalls and controversies

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Abstract

Although certain neuroimaging appearances are highly suggestive of abuse, radiological findings are often nonspecific. The objective of this review is to discuss pitfalls, controversies, and mimics occurring in neuroimaging of nonaccidental head trauma in order to allow the reader to establish an increased level of comfort in distinguishing between nonaccidental and accidental head trauma. Specific topics discussed include risk factors, general biomechanics and imaging strategies in nonaccidental head trauma, followed by the characteristics of skull fractures, normal prominent tentorium and falx versus subdural hematoma, birth trauma versus nonaccidental head trauma, hyperacute versus acute on chronic subdural hematomas, expanded subarachnoid space versus subdural hemorrhage, controversy regarding subdural hematomas associated with benign enlarged subarachnoid spaces, controversy regarding hypoxia as a cause of subdural hematoma and/or retinal hemorrhages without trauma, controversy regarding the significance of retinal hemorrhages related to nonaccidental head trauma, controversy regarding the significance of subdural hematomas in general, and pitfalls of glutaric aciduria type 1 and hemophagocytic lymphohistiocytosis mimicking nonaccidental head trauma.

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References

  1. Bonnier C, Nassogne MC, Saint-Martin C et al (2003) Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome. Pediatrics 112:808–814

    Article  PubMed  Google Scholar 

  2. Bruce DA, Zimmerman RA (1989) Shaken impact syndrome. Pediatr Ann 18:482–492

    PubMed  CAS  Google Scholar 

  3. Keenan HT, Runyan DK, Marshall SW et al (2003) A population-based study of inflicted traumatic brain injury in young children. JAMA 290:621–626

    Article  PubMed  Google Scholar 

  4. Reece RM, Sege R (2000) Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med 154:11–15

    PubMed  CAS  Google Scholar 

  5. Gessner BD, Moore M, Hamilton B et al (2004) The incidence of infant physical abuse in Alaska. Child Abuse Negl 28:9–23

    Article  PubMed  Google Scholar 

  6. Schnitzer PG, Ewigman BG (2005) Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics 116:e687–e693

    Article  PubMed  Google Scholar 

  7. Boos SC (2007) Biomechanics of non-accidental head trauma: a work in progress. In: Gyrations 2:2–4. http://www.aspnr.org. Accessed 3 Dec 2007

  8. Case ME, Graham MA, Handy TC et al (2001) Position paper on fatal abusive head injuries in infants and young children. Am J Forensic Med Pathol 22:112–122

    Article  PubMed  CAS  Google Scholar 

  9. Hymel KP, Makoroff KL, Laskey AL et al (2007) Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. Pediatrics 119:922–929

    Article  PubMed  Google Scholar 

  10. Lonergan GJ, Baker AM, Morey MK et al (2003) From the archives of the AFIP. Child abuse: radiologic-pathologic correlation. Radiographics 23:811–845

    Article  PubMed  Google Scholar 

  11. Duhaime AC, Alario AJ, Lewander WJ et al (1992) Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 90:179–185

    PubMed  CAS  Google Scholar 

  12. Duhaime AC, Gennarelli TA, Thibault LE et al (1987) The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 66:409–415

    PubMed  CAS  Google Scholar 

  13. Frazier LD (2007) Neuroradiologist/pediatrician collaboration in suspected abusive head trauma. Gyrations 2:4–5

    Google Scholar 

  14. Conway JJ, Collins M, Tanz RR et al (1993) The role of bone scintigraphy in detecting child abuse. Semin Nucl Med 23:321–333

    Article  PubMed  CAS  Google Scholar 

  15. Hymel KP, Rumack CM, Hay TC et al (1997) Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma. Pediatr Radiol 27:743–747

    Article  PubMed  CAS  Google Scholar 

  16. Barnes PD (2007) Imaging of the central nervous system (CNS) in suspected or alleged non-accidental injury. In: Gyrations 2:5–7. http://www.aspnr.org. Accessed 3 Dec 2007

  17. Soul JS, Robertson RL, Tzika AA et al (2001) Time course of changes in diffusion-weighted magnetic resonance imaging in a case of neonatal encephalopathy with defined onset and duration of hypoxic-ischemic insult. Pediatrics 108:1211–1214

    Article  PubMed  CAS  Google Scholar 

  18. Suh DY, Davis PC, Hopkins KL et al (2001) Nonaccidental pediatric head injury: diffusion-weighted imaging findings. Neurosurgery 49:309–318; discussion 318–320

    Article  PubMed  CAS  Google Scholar 

  19. Kleinman PK, Ragland RL (1996) Gadopentetate dimeglumine-enhanced MR imaging of subdural hematoma in an abused infant. AJR 166:1456–1458

    PubMed  CAS  Google Scholar 

  20. Chen CY, Huang CC, Zimmerman RA et al (2001) High-resolution cranial ultrasound in the shaken-baby syndrome. Neuroradiology 43:653–661

    Article  PubMed  CAS  Google Scholar 

  21. Jaspan T, Narborough G, Punt JA et al (1992) Cerebral contusional tears as a marker of child abuse – detection by cranial sonography. Pediatr Radiol 22:237–245

    Article  PubMed  CAS  Google Scholar 

  22. Amodio J, Spektor V, Pramanik B et al (2005) Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces. Pediatr Radiol 35:1113–1117

    Article  PubMed  Google Scholar 

  23. Poussaint TY, Moeller KK (2002) Imaging of pediatric head trauma. Neuroimaging Clin N Am 12:271–294, ix

    Article  PubMed  Google Scholar 

  24. Lowe LH, Bulas DI (2005) Transcranial Doppler imaging in children: sickle cell screening and beyond. Pediatr Radiol 35:54–65

    Article  PubMed  Google Scholar 

  25. King J, Diefendorf D, Apthorp J et al (1988) Analysis of 429 fractures in 189 battered children. J Pediatr Orthop 8:585–589

    PubMed  CAS  Google Scholar 

  26. Arnholz D, Hymel KP, Hay TC et al (1998) Bilateral pediatric skull fractures: accident or abuse? J Trauma 45:172–174

    PubMed  CAS  Google Scholar 

  27. Meservy CJ, Towbin R, McLaurin RL et al (1987) Radiographic characteristics of skull fractures resulting from child abuse. AJR 149:173–175

    PubMed  CAS  Google Scholar 

  28. Kleinman PK, Spevak MR (1992) Soft tissue swelling and acute skull fractures. J Pediatr 121:737–739

    Article  PubMed  CAS  Google Scholar 

  29. Seifert D, Puschel K (2006) Subgaleal hematoma in child abuse. Forensic Sci Int 157:131–133

    Article  PubMed  CAS  Google Scholar 

  30. Kilani RA, Wetmore J (2006) Neonatal subgaleal hematoma: presentation and outcome – radiological findings and factors associated with mortality. Am J Perinatol 23:41–48

    Article  PubMed  Google Scholar 

  31. Zimmerman RD, Yurberg E, Russell EJ et al (1982) Falx and interhemispheric fissure on axial CT: I. Normal anatomy. AJR 138:899–904

    PubMed  CAS  Google Scholar 

  32. Zimmerman RD, Russell EJ, Yurberg E et al (1982) Falx and interhemispheric fissure on axial CT: II. Recognition and differentiation of interhemispheric subarachnoid and subdural hemorrhage. AJNR 3:635–642

    PubMed  CAS  Google Scholar 

  33. Han BK, Towbin RB, De Courten-Myers G et al (1990) Reversal sign on CT: effect of anoxic/ischemic cerebral injury in children. AJR 154:361–368

    PubMed  CAS  Google Scholar 

  34. Parker LA (2005) Part 1: early recognition and treatment of birth trauma: injuries to the head and face. Adv Neonatal Care 5:288–297; quiz 298–300

    Article  PubMed  Google Scholar 

  35. Whitby EH, Griffiths PD, Rutter S et al (2004) Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 363:846–851

    Article  PubMed  CAS  Google Scholar 

  36. Barnes PD, Robson CD (2000) CT findings in hyperacute nonaccidental brain injury. Pediatr Radiol 30:74–81

    Article  PubMed  CAS  Google Scholar 

  37. Greenberg J, Cohen WA, Cooper PR (1985) The “hyperacute” extraaxial intracranial hematoma: computed tomographic findings and clinical significance. Neurosurgery 17:48–56

    Article  PubMed  CAS  Google Scholar 

  38. Sargent S, Kennedy JG, Kaplan JA (1996) “Hyperacute” subdural hematoma: CT mimic of recurrent episodes of bleeding in the setting of child abuse. J Forensic Sci 41:314–316

    PubMed  CAS  Google Scholar 

  39. Ravid S, Maytal J (2003) External hydrocephalus: a probable cause for subdural hematoma in infancy. Pediatr Neurol 28:139–141

    Article  PubMed  Google Scholar 

  40. Rupprecht T, Lauffer K, Storr U et al (1996) Extra-cerebral intracranial fluid collections in childhood: differentiation between benign subarachnoid space enlargement and subdural effusion using color-coded duplex ultrasound. Klin Padiatr 208:97–102

    PubMed  CAS  Google Scholar 

  41. Hymel KP, Jenny C, Block RW (2002) Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies. Child Maltreat 7:329–348

    Article  PubMed  Google Scholar 

  42. Piatt JH Jr (1999) A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages. Neurosurg Focus 7:e4

    Article  PubMed  Google Scholar 

  43. Pittman T (2003) Significance of a subdural hematoma in a child with external hydrocephalus. Pediatr Neurosurg 39:57–59

    Article  PubMed  Google Scholar 

  44. Geddes JF, Tasker RC, Hackshaw AK et al (2003) Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol 29:14–22

    Article  PubMed  CAS  Google Scholar 

  45. Goetting MG, Sowa B (1990) Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics 85:585–588

    PubMed  CAS  Google Scholar 

  46. Odom A, Christ E, Kerr N et al (1997) Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics 99:E3

    Article  PubMed  CAS  Google Scholar 

  47. Punt J, Bonshek RE, Jaspan T et al (2004) The ‘unified hypothesis’ of Geddes et al. is not supported by the data. Pediatr Rehabil 7:173–184

    Article  PubMed  CAS  Google Scholar 

  48. Richards PG, Bertocci GE, Bonshek RE et al (2006) Shaken baby syndrome. Arch Dis Child 91:205–206

    Article  PubMed  CAS  Google Scholar 

  49. Smith C, Bell JE, Keeling JW et al (2003) Dural haemorrhage in nontraumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Geddes JE et al. A response. Neuropathol Appl Neurobiol 29:411–412; author reply 412–413

    Article  PubMed  CAS  Google Scholar 

  50. Ghatan S, Ellenbogen RG (2002) Pediatric spine and spinal cord injury after inflicted trauma. Neurosurg Clin N Am 13:227–233

    Article  PubMed  Google Scholar 

  51. Kleinman PK, Shelton YA (1997) Hangman’s fracture in an abused infant: imaging features. Pediatr Radiol 27:776–777

    Article  PubMed  CAS  Google Scholar 

  52. Rooks VJ, Sisler C, Burton B (1998) Cervical spine injury in child abuse: report of two cases. Pediatr Radiol 28:193–195

    Article  PubMed  CAS  Google Scholar 

  53. Thomas NH, Robinson L, Evans A et al (1995) The floppy infant: a new manifestation of nonaccidental injury. Pediatr Neurosurg 23:188–191

    Article  PubMed  CAS  Google Scholar 

  54. Hymel KP, Hall CA (2005) Diagnosing pediatric head trauma. Pediatr Ann 34:358–370

    PubMed  Google Scholar 

  55. Bechtel K, Stoessel K, Leventhal JM et al (2004) Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 114:165–168

    Article  PubMed  Google Scholar 

  56. Pitetti RD, Maffei F, Chang K et al (2002) Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event. Pediatrics 110:557–562

    Article  PubMed  Google Scholar 

  57. Alexander RC, Schor DP, Smith WL Jr (1986) Magnetic resonance imaging of intracranial injuries from child abuse. J Pediatr 109:975–979

    Article  PubMed  CAS  Google Scholar 

  58. Levin AV, Ells A, Schloff S (2004) Suspected child abuse victims. Ophthalmology 111:1794; author reply 1794–1795

    Article  PubMed  Google Scholar 

  59. Morad Y, Kim YM, Armstrong DC et al (2002) Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 134:354–359

    Article  PubMed  Google Scholar 

  60. Levin AV (2001) Ocular manifestations of child abuse. Lippincott Williams and Wilkins, Philadelphia

    Google Scholar 

  61. Gnanaraj L, Gilliland MG, Yahya RR et al (2007) Ocular manifestations of crush head injury in children. Eye 21:5–10

    Article  PubMed  CAS  Google Scholar 

  62. Merten DF, Osborne DR, Radkowski MA et al (1984) Craniocerebral trauma in the child abuse syndrome: radiological observations. Pediatr Radiol 14:272–277

    Article  PubMed  CAS  Google Scholar 

  63. Maxeiner H (2001) Demonstration and interpretation of bridging vein ruptures in cases of infantile subdural bleedings. J Forensic Sci 46:85–93

    PubMed  CAS  Google Scholar 

  64. Ikeda A, Sato O, Tsugane R et al (1987) Infantile acute subdural hematoma. Childs Nerv Syst 3:19–22

    Article  PubMed  CAS  Google Scholar 

  65. Knapp JF, Soden SE, Dasouki MJ et al (2002) A 9-month-old baby with subdural hematomas, retinal hemorrhages, and developmental delay. Pediatr Emerg Care 18:44–47

    Article  PubMed  Google Scholar 

  66. Hartley LM, Khwaja OS, Verity CM (2001) Glutaric aciduria type 1 and nonaccidental head injury. Pediatrics 107:174–175

    Article  PubMed  CAS  Google Scholar 

  67. Rooms L, Fitzgerald N, McClain KL (2003) Hemophagocytic lymphohistiocytosis masquerading as child abuse: presentation of three cases and review of central nervous system findings in hemophagocytic lymphohistiocytosis. Pediatrics 111:e636–640

    Article  PubMed  Google Scholar 

  68. Fitzgerald NE, MacClain KL (2003) Imaging characteristics of hemophagocytic lymphohistiocytosis. Pediatr Radiol 33:392–401

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, University of Missouri-Kansas School of Medicine, Kansas City, MO, USA

    Sujan Fernando

  2. Department of Radiology, The University of Kansas Medical Center, Kansas City, MO, USA

    Ruby E. Obaldo

  3. Department of Emergency Medicine, The University of Missouri-Kansas City, Children’s Mercy Hospitals and Clinics, Kansas City, MO, USA

    Irene R. Walsh

  4. Department of Radiology, The University of Missouri-Kansas City, Children’s Mercy Hospitals and Clinics, Kansas City, MO, USA

    Lisa H. Lowe

  5. 7306 W. 57th St., Mission, KS, 66202, USA

    Sujan Fernando

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  1. Sujan Fernando
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Correspondence to Sujan Fernando.

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Fernando, S., Obaldo, R.E., Walsh, I.R. et al. Neuroimaging of nonaccidental head trauma: pitfalls and controversies. Pediatr Radiol 38, 827–838 (2008). https://doi.org/10.1007/s00247-007-0729-1

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  • DOI: https://doi.org/10.1007/s00247-007-0729-1

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