Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants

Abstract

For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the “consensus” opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson’s syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.

An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse

“…However, subdural hemorrhage, injury to the posterior region of the head or occipital lobe, a Glasgow coma score (GCS) below 15, convulsive episodes and vomiting have been suggested to be fairly reliable predictors of retinal hemorrhage [4,5]. Nevertheless, clinicians are expected to be wary of pitfalls with regard to this delicate issue, as the co-occurrence of subdural and retinal hemorrhage cannot irrefutably indicate AHT, when there is precedent that such clinical picture might be suggestive of life-threatening conditions such as cerebral venous sinus thrombosis, which falls within the category of coagulopathies [6]. In the case of younger children or infants, the situation is substantially more complicated because retinal hemorrhage in infants often occurs secondary to an underlying intracranial pathology of unknown origin [7].…”

Neuroradiological findings in children with subdural hematoma and suspected abusive head trauma

“…Cortical vein thrombosis (Figure 4) has traditionally been regarded as an important sign of AHT, where the proposed mechanism is a trauma leading to bridging vein rupture/damage, followed by a formation of blood clot/thrombosis 37 . In a recent study, however, Vaslow 38 reported several infants with chronic SDH and cortical vein thrombosis. This again was associated with retinal hemorrhage and neurological decline, leading the authors to question the supposed connection between cortical vein thrombosis and AHT.…”

Understanding Acquired Brain Injury: A Review

“…Various types of intracranial hematomas, as well as intraventricular hematomas and brain tissue contusions, can occur from injury to the cerebrovasculature in the affected areas. These particulate lesions can cause a mass effect, as well as an upsurge in ICP and brain herniation [ 17 , 65 , 67 , 68 ]. As a primary injury, brain laceration may predispose the sufferer to convulsions and epilepsy [ 69 , 70 ].…”