J Korean Neurosurg Soc.  2022 May;65(3):385-396. 10.3340/jkns.2021.0289.

Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants

• Park YS

• KMID: 2529583
• DOI: http://doi.org/10.3340/jkns.2021.0289

Abstract

Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.

Keyword

Child abuse; Acute subdural hematoma; Hypoxia-Ischemia; Outcome; Pathophysiology

Figure

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  Fig. 1. A : A typical computed tomography image of the so-called “Big Black Brain” showing hypodensity of the bilateral cerebral hemispheres. No lesions extend to the basal ganglia and thalamus. B : This case shows hypodensity of the entire cerebrum including the bilateral basal ganglia and thalamus on the initial computed tomography when transported to the hospital.

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  Fig. 2. This case was transferred to the hospital with the chief complaint of cardiopulmonary arrest. Head computed tomography findings indicate that an extensive low-density area is widespread in the bilateral cerebrum, including the basal ganglia and thalamus, with no midline shift.

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  Fig. 3. An extensive low-density area is observed in the right cerebral hemisphere with a severe midline shift. The amount of subdural hematoma is small.

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  Fig. 4. A : Compute tomography on the day of abusive head trauma. B : Computed tomography performed 3 days after injury, a low-density area appeared locally appeared in the right frontal and parietal lobes (arrows).

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  Fig. 5. A : Compute tomography on the day of abusive head trauma. B : Compute tomography performed 2 days after craniotomy, a low-density area locally appeared in the right frontal lobe and bilateral parieto-occipital lobes (arrows). These appearances are not due to a cerebral herniation.

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  Fig. 6. A : Compute tomography (CT) on the day of head injury. B : Two days after craniotomy. CT shows an extensive low-density area in the right parietal lobe (arrow), fluid attenuated inversion recovery imaging shows diffuse high intensity in the right cerebral hemisphere, and arterial spin labeling imaging shows hyperperfusion at the same site.

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  Fig. 7. Severe cerebral atrophy occurred 3 weeks after abusive head trauma (1-month-old boy).

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  Fig. 8. A : A case of cardiopulmonary arrest (2-year-old girl) shows traumatic subarachnoid hemorrhage in the perimesencephalic cistern. B : A case of cardiopulmonary arrest (11-month-old girl) shows diffuse brain swelling immediately after head injury.

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  Fig. 9. A case of cardiopulmonary arrest (4-month-old girl). A : Compute tomography shows acute subdural hematoma and typical hypoxic ischemic encephalopathy. B : Susceptibility weighted imaging image does not show traumatic primary damage to the brain parenchyma. C : Cervical cord magnetic resonance imaging also does not show traumatic lesions.

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  Fig. 10. A : A case of cardiopulmonary arrest (6-month-old boy) shows retro clival hematoma, indirectly indicating medulla oblongata injury. B : A case of cardiopulmonary arrest (11-month-old girl) shows severe brain stem swelling immediately after injury.

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  Fig. 11. A case of cardiopulmonary arrest (4-year-old boy) shows upper cervical cord stem swelling in the postmortem spine T2 weighted magnetic resonance imaging.

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  Fig. 12. A cardiopulmonary arrest case (1-year-old girl) shows multiple trivial intracranial hematomata. However, there are no other serious primary brain parenchymal injuries. We conclude that the cause of cardiopulmonary arrest is asphyxia after vomiting.

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  Fig. 13. Requirements for appropriate abusive head trauma judgment. SBS : shaken baby syndrome, ASDH : acute subdural hematoma, CT : computed tomography, MRI : magnetic resonance imaging, eLDA : extensive low-density area, BBB : big black brain, AHT : abusive head trauma.

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  Fig. 14. Complex mechanism of poor outcome in infantile acute subdural hematoma, especially in abusive head trauma cases. DAI : diffuse axonal injury, SBS : shaken baby syndrome.

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  Fig. 15. A : A 4-month-old girl with severe disturbance of consciousness. Computed tomography (CT) shows a low-density area in both the right cerebral hemisphere and the anterior area of the left frontal lobe, implicating an impaired blood flow in the right internal carotid artery. B : A 3-month-old boy with cardiopulmonary arrest. CT shows a low-density area in not only the brain stem but also in the thalamus and occipital lobes bilaterally and was considered to be impaired blood flow in the basilar artery.

Reference

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