Imaging of the Central Nervous System in Suspected or Alleged Nonaccidental Injury, Including the Mimics

SUMMARY: Unexplained SDH in infants and children is an accepted marker for AHT. It has been proposed that IVT may be the initiating event leading to the development of acute SDH, mimicking the appearance of traumatic SDH. Our study aims to investigate if nontraumatic IVT causes SDH in the pediatric population. We retrospectively identified 36 patients with IVT and reviewed neuroimaging studies for the concurrent presence of SDH. In our 36 patients with IVT, no associated SDH was observed. Even with extensive IVT, no SDH was present. Three false-positive diagnoses of IVT were identified in the setting of mastoiditis and traumatic SDH, demonstrating pitfalls in imaging. In conclusion, our findings do not support the previous AHT literature stating that IVT is associated with, or leads to, SDH in neonates, infants, or children.ABBREVIATIONS: AHT ϭ abusive head trauma; CECT ϭ contrast-enhanced CT; CI ϭ confidence interval; CVT ϭ cortical vein thrombosis; FOV ϭ field of view; GRE ϭ gradient recalled echo; ICV ϭ internal cerebral veins; IVT ϭ intracranial venous thrombosis; MIP ϭ maximum intensity projection; SDH ϭ subdural hematoma/hemorrhage; SPGR ϭ spoiled gradient-recalled; TOF ϭ time-of-flight I VT, which is defined as CVT and/or dural venous sinus thrombosis, is relatively rare in children and young adults. It is often associated with underlying disease states that predispose a patient to a thrombotic event. SDH is also rare in the neonate, infant, and young child, and is usually associated with trauma, infection, thrombogenic states, and less often with other causes.1 IVT occurs with an estimated prevalence of 0.67/100,000 among infants in the first year of life.2 Neonates account for a significant number of pediatric cases. Risk factors for neonatal IVT include polycythemia, other prothrombotic states, and perinatal complications such as head trauma, asphyxia, sepsis, and meningitis. Spontaneous IVT has been described in infants and children, and is frequently due to an underlying condition such as infection, shock, dehydration, hypercoagulable states, iron deficiency anemia, and tumors. 3 However, in a review of the literature, very few cases of IVT were associated with SDH.AHT in neonates, infants, and young children is a complex diagnosis, requiring the interaction of pediatrics, radiology, ophthalmology, and the child protection team. Commonly, young infants present for medical care with unexplained neurologic symptoms, and the diagnosis of a SDH is made based upon imaging. The diagnosis of AHT is then subsequently established through a process that ties medical opinions with history, assessment of other injuries, and investigative results. Patients with AHT may develop IVT as a consequence of intracranial injury. Most such patients also often have other indicators of abusive injury such as fractures, bruises, and retinal hemorrhages. Only recently has IVT been proposed as the initiating event for extra-axial hemorrhage, such as SDH and subarachnoid hemorrhage, in the pediatric population. The theory sugge...

Section: Discussionmentioning

confidence: 75%

Does Intracranial Venous Thrombosis Cause Subdural Hemorrhage in the Pediatric Population?

McLean

Frasier

Hedlund

2012

“…[1][2][3][4][5][6][7][8][9][10][11][12][13] Birthrelated trauma is used in the court of law as an explanation for SDH in infants with suspected NAI because a variety of hemorrhages have been reported in term neonates. A study of the appearance and natural evolution of these birth-related hemorrhages, particularly SDH, is important in the forensic evaluation of NAI.…”

mentioning

confidence: 99%

Prevalence and Evolution of Intracranial Hemorrhage in Asymptomatic Term Infants

Rooks¹,

Eaton²,

Ruess³

et al. 2008

257

197

BACKGROUND AND PURPOSE:Subdural hemorrhage (SDH) is often associated with infants experiencing nonaccidental injury (NAI). A study of the appearance and natural evolution of these birth-related hemorrhages, particularly SDH, is important in the forensic evaluation of NAI. The purpose of this study was to determine the normal incidence, size, distribution, and natural history of SDH in asymptomatic term neonates as detected by sonography (US) and MR imaging within 72 hours of birth.

“…50,51,88 However, all these smooth differencing criteria should be handled with care. "Three weeks" cannot be a strict borderline, and most of the aforementioned pathophysiologic data regarding cSDH rely on studies in adults.…”

Section: Differential Diagnoses Of Subdural Hygromasmentioning

confidence: 99%

Subdural Hygromas in Abusive Head Trauma: Pathogenesis, Diagnosis, and Forensic Implications

Wittschieber¹,

Karger²,

Niederstadt

et al. 2014

SUMMARY:Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan. ABBREVIATIONS:AHT ϭ abusive head trauma; BESS ϭ benign enlargement of subarachnoid space; BV ϭ bridging vein; cSDH ϭ chronic subdural hematoma;