J Korean Neurosurg Soc.  2022 May;65(3):397-407. 10.3340/jkns.2021.0297.

Imaging of Abusive Head Trauma : A Radiologists’ Perspective

• Cheon JE
• Kim JH

• KMID: 2529584
• DOI: http://doi.org/10.3340/jkns.2021.0297

Abstract

Abusive head trauma (AHT) is the most common and serious form of child abuse and a leading cause of traumatic death in infants and young children. The biomechanics of head injuries include violent shaking, blunt impact, or a combination of both. Neuroimaging plays an important role in recognizing and distinguishing abusive injuries from lesions from accidental trauma or other causes, because clinical presentation and medical history are often nonspecific and ambiguous in this age group. Understanding common imaging features of AHT can increase recognition with high specificity for AHT. In this review, we discuss the biomechanics of AHT, imaging features of AHT, and other conditions that mimic AHT.

Keyword

Child abuse; Neuroimaging; Infant

Figure

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  Fig. 1. Illustration explaining the mechanism of abusive head trauma by vigorous shaking of the baby. Rapid alternating angular acceleration and deceleration of the head results in subdural hemorrhage, parenchymal injury, and retinal hemorrhage, often without external signs of injury.

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  Fig. 2. Three-month-old boy with seizure-like movements, multiple bruises, and retinal hemorrhage. A : Non-contrast-enhanced computed tomography image shows bilateral subdural fluid and ill-defined low attenuation of the cerebral parenchyma. B and C : Follow-up magnetic resonance images reveal an atrophic brain with multifocal tissue loss and increased amount of subdural hemorrhage (SDH) at both convexities, which shows higher signal intensity than that of the cerebrospinal fluid on both T1- (B) and T2- (C) weighted image. Separated compartments with fluid levels (arrows) containing blood products exhibiting different signal intensities are suggestive of multistage SDH.

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  Fig. 3. Four-month-old girl observed with lethargy and whole-body cyanosis in bed. A : Initial Non-contrast-enhanced computed tomography (NECT) at the level of the vertex shows multiple small high-density hemorrhages (arrows) at the gyral surface. B and C : Follow-up T2-weighted image (T2WI) (B) and gradient echo image (C) at the same level demonstrate multiple dark signal intensities (arrows) at the site of bridging vein rupture. Focal distension or blooming of the veins is suggestive of clots or thrombi. D : NECT obtained 2 days after the initial CT shows subdural hemorrhage posteriorly (arrows) and rapid onset bilateral subdural hygroma at the convexities. E : T2WI shows ill-defined increase in signal intensity of the cerebral hemispheres and splenium (arrow). F : Diffusion weighted image also shows increased signal intensity in the splenium (arrow), as well as both occipital lobes, and gray-white junction of the left frontal lobe. Diverse degrees of apparent diffusion coefficient (ADC) decline was demonstrated on an ADC map (not shown). G : Axial gradient echo images reveal tiny dark spots at the posterior wall of both eyes, indicating retinal hemorrhage (arrows). Hemorrhage is also noted in the right anterior chamber (black arrow). Although she had only a minor trauma history of being bumped into the door, skeletal survey revealed fracture of the clavicle, metacarpal bone, and spine, and eye examination disclosed fresh, multifocal, and multi-layered retinal hemorrhage.

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  Fig. 4. Two-month-old girl with a history of minor trauma. A and B : Anteroposterior (AP) and lateral skull radiographs demonstrate multiple linear fractures (arrows) of eggshell type. C : Non-contrast-enhanced computed tomography (NECT) coronal reconstructed image well demonstrates high density subdural hemorrhage adjacent to the falx and tentorium (arrows), as well as scalp swelling with hemorrhage. Ill-defined, decreased attenuation of the parenchyma suggests an acute edematous lesion. D : Bone window setting image clearly shows multifocal fracture and displaced fragments (arrows). E : Coronal T2-weighted image (T2WI) shows hemorrhagic contusion of the left temporal lobe (arrowhead), extra-parenchymal fluid or hemorrhage, and increased signal intensity at the parasagittal areas (arrows) suggest watershed injury. F : Diffusion restriction is mainly distributed in parasagittal areas and posterior thalami (arrows), although other parts of the brain are involved, on an apparent diffusion coefficient (ADC) map. G : The areas of ADC decline and T2 high intensity eventually evolved to a severe encephalomalacia on a follow-up T2WI.

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  Fig. 5. Five-month-old girl with incidentally detected subdural hemorrhage (SDH) during follow-up for retinoblastoma, and another episode of head trauma. A : Small amount of left frontal SDH (arrow) is incidentally noted on a coronal T1-weighted image (T1WI) of the orbit magnetic resonance imaging (MRI). B : Subsequent contrast-enhanced computed tomography for evaluation of abusive head trauma shows bilateral subarachnoid space widening where enhanced vessels are traversing. Note a localized cerebrospinal fluid space at the left frontal convexity (arrow) displacing a vascular structure, that corresponds to the subdural collection noted on a previous MRI (A). There is no visible skull fracture. C : Skull radiography, obtained after a week, when the baby was presented to the emergency room for irritability and scalp swelling, reveals linear fracture of the left parietal bone (arrow). D : Non-contrast-enhanced computed tomography shows SDH at the right convexity (arrow), while there is a hemorrhagic swelling of the left scalp adjacent to the left parietal fracture site. Eye examination under anesthesia revealed regressed calcified tumor and retinal hemorrhage.

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  Fig. 6. Three-month-old boy with a growing skull fracture and repeated head injury. A and B : Anteroposterior (AP) and lateral skull radiographs show a displaced fracture margin (arrows in A) and an enlarged defect (arrows in B). C : Volume-rendered computed tomography image demonstrates a complex defect caused by a displaced fracture margin (arrows), suggesting a “growing fracture.” D : Coronal T2-weighted image (T2WI) demonstrates a herniated pseudomeningocele or leptomeningeal cyst (arrow) via the enlarged fracture defect and focal parenchymal laceration (black arrow). E : Follow-up non-contrast-enhanced computed tomography obtained 2 weeks after reveals multifocal additional high-density hemorrhage in the protruded meningeal sac, parenchyma, and para-falcine areas (arrows) and parenchymal lesions of low attenuation (black arrow), suggesting repeated injury. Past medical records revealed repeated episodes of physical injury, and skeletal survey demonstrated multistage fracture of the bones.

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  Fig. 7. Six-month-old girl found in a comatose state at home. A : Skull anteroposterior radiography shows multiple skull fractures (arrows). B and C : Subsequent non-contrast-enhanced computed tomography images demonstrate extensive brain edema with high attenuation at the basal cistern (sign of pseudo-subarachnoid hemorrhage) and tentorial areas. Note multifocal small subdural hemorrhages (arrows) in the computed tomography (B) and sagittal T1-weighted image (D). E : T2-weighted image also shows massive cerebral swelling. Eye exam revealed retinal detachment and hemorrhage.

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  Fig. 8. Neonate with presumed birth-related subdural hemorrhage (SDH). Sagittal T1-weighted image shows a small amount of SDH (arrow) in the posterior fossa.

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  Fig. 9. Infant with type 1 glutaric aciduria. A : Axial T2-weighted image (T2WI) shows bilateral subdural fluid collection (arrows). There are multifocal high signal intensity lesions at the globi pallidi, thalimi, and white matter. B : Typical hypoplastic opercula (arrows) became evident by the resolution of the subdural fluid on follow-up T2WI. There are additional parenchymal lesions exhibiting high intensity at the frontal white matter, thalami, and midbrain.

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  Fig. 10. Infant with Menkes disease. A : T2-weighted image shows very tortuous arteries (arrows) and multifocal high intensity in the white matter. B : Fluid attenuated inversion recovery image shows a small amount of subdural hemorrhage (arrow) at the left convexity, which is associated with mild brain atrophy. C : Magnetic resonance angiography demonstrates the “kinky vessels,” a typical finding of the trichopoliodystrophy (Menkes disease).

Reference

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