Inflicted Traumatic Brain Injury in Infants and Young Children

Abstract

This article will discuss the subject of inflicted or abusive head injury in infants and young children. Inflicted neurotrauma is a very common injury and a frequent problem in attempting to distinguish between inflicted and accidental injury. Inflicted head injury occurs usually in the home in the presence of the individual who has inflicted the injury outside the view of unbiased witnesses. Distinguishing between inflicted and accidental injury may be dependent upon the pathological findings and consideration of the circumstances surrounding the injury. The most common finding in an inflicted head injury is the presence of subdural hemorrhage. Subdural hemorrhage may occur in a variety of distributions and appearances. The natural history of subdural bleeding and the anatomy of the "subdural" will be considered. The anatomy of the dura and its attachment to the skull and to the arachnoid determines how subdural bleeding evolves into the cleaved dural border cell layer and as well as how bridging veins are torn and anatomically where bleeding will occur. Different biomechanical mechanisms result in different distributions of subdural blood and these differences will be discussed.

Pediatric Neurocritical Care

“…Subarachnoid hemorrhages and hypoxic ischemic injury are also commonly seen [22,23]. It has been postulated that hypoxic-ischemic injury with iTBI may be related to apnea from traumatic injury to the brainstem or rotational acceleration-deceleration forces causing deep focal injuries that might contribute directly to cardiorespiratory compromise [24].…”

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

“…Liquid remnants of the acute SDH or CSF might then pass into that opened space by effusion from surrounding vessels or even the subarachnoid space, forming the SDHy. 50,52 It should be noticed that in this approach, the SDHy is considered as a consequence of the SDH but not as a directly transformed remnant of it. Alternatively, Mack et al 36 suggested that CSF could physiologically move from the subarachnoid space into interstitial spaces of the dura mater and subsequently via the dural venous plexus into the dural sinuses.…”

“…If the decreased intracranial pressure that had led to SDHy formation continues, the SDHy may expand. 50,52 This can enlarge the intradural cleavage (ϭ subdural space filled with SDHy) up to the opposite brain side opening a subdural space even above the falx cerebri. Accordingly, SDHys were frequently observed not to be restricted to the brain side of the "original pathology" (eg, acute SDH).…”

“…33,[37][38][39][49][50][51]53,[70][71][72] Hence, SDHy can result from trauma and from cranial operations in which the arachnoid membrane is opened, leading to CSF transfer into the subdural space. 33 For this, the term acute SDHy has been suggested.…”

“…22,37,[42][43][44][45][46][47] Likewise, if the principal component of a subdural collection appears to be CSF-like, the term SDHy is used. 44,[48][49][50] A mixture of blood and CSF is referred to as hematohygroma. [51][52][53][54] The heterogeneous appearances of SDHys prompted Unterharnscheidt 37 to differentiate between 2 general morphologic types:…”