Child Abuse Neurological Injury

  • Etiology:
    — Direct trauma -> skull fracture (can be multiple, complex), contusion (coup/contrecoup)
    — Shaking -> rotational injury, subdural hematoma (interhemispheric), subarachnoid hemorrhage, contusions, white matter tear/laceration, cervicomedullary stretch -> apnea – > hypoxia / ischemia
  • Imaging:
    — Subdural hematoma is most common intracranial manifestation
    — Subdural hematoma can resolve rapidly due to washout from cerebrospinal fluid and redistribution
    — Chronic subdural hematoma with enhancing membrane can be seen at around 1 week
    — Spontaneous rebleeding into chronic subdural hematoma is rare in infants unless there is underlying cerebral atrophy or ventriculoperitoneal shunt with low intracranial pressure
    — Mixed density subdural hematoma is due to acute cerebrospinal fluid from tear in arachnoid membrane mixing with acute blood, early clot retraction, acute unclotted blood, acute hemorrhage into chronic subdural hematoma
  • Note: may have associated hemorrhage in the spinal canal
  • DDX: benign enlargement of the subarachnoid space can mimic chronic bilateral subdural hematomas
  • Complications: intracranial herniation
  • Clinical: intracranial injury is the most common cause of death

Cases of Child Abuse Neurological Injury

Radiograph of a linear skull fracture
Lateral radiograph of the skull shows bilateral linear parietal lucencies coursing across the skull.
Radiograph of parietal skull fracture and CT of chronic subdural hematomas in child abuse
AP radiograph of the skull shows a linear lucency in the left parietal bone that connects to the left lambdoid suture. Axial CT without contrast of the brain shows bilateral low density extra-axial fluid collections around the brain.
MRI of acute and chronic subdural hematomas in child abuse
Axial CT without contrast of the brain (upper left) shows bilateral large low density extra-axial fluid collections and a left frontal small high density extra-axial fluid collection. There is also prominence of the cortical sulci and the ventricular system. Axial T1 (upper right), T2 (lower left) and FLAIR (lower right) MRI without contrast of the brain better demonstrates the extra-axial fluid collections with the bilateral large collections being bright on T1 and T2 and the small left frontal collection being iso on T1 and dark on T2.
Radiograph of stellate skull fracture and CT of acute subdural hematoma due to accidental trauma
AP and lateral radiographs of the skull show numerous branching lucencies in the right parietal bone. Axial CT without contrast of the brain shows high density material in the right subgaleal tissues, a small high density cresenteric fluid collection in the right extra-axial space that extends posteriorly along the falx, and a mixed low-density and high density lesion in the right posterior parietal brain parenchyma.
CT of subgaleal hematoma, diastatic skull fracture, depressed skull fracture, cerebellar contusion, diffuse cerebral edema in child abuse
Axial CT without contrast of the brain shows high density material in the subgaleal tissues posteriorly, a wide lucency in the right posterior skull along with two areas of depressed lucency in the left frontal skull, a rounded high-density lesion in the midline of the cerebellum, and decreased density of the cerebrum when compared to the normal density of the cerebellum along with loss of the normal gray matter-white matter differentiation.
CT of acute and chronic subdural hematomas in child abuse
Axial (above) and coronal (below) CT without contrast of the brain shows a right moderate sized high density cresenteric extra-axial fluid collection that extends around the entire right cerebral hemisphere as well as interhemispherically. There is also a left moderate sized low-density cresenteric extra-axial fluid collection.
CT of tricompartmental chronic subdural hematomas in child abuse
Axial CT without contrast of the brain shows very large low density extra-axial fluid collections supratentorially around the left and right cerebral hemispheres and infratentorially around the cerebellum. There is also a round high density focus along the posterior right falx.
CT of diffuse cerebral edema in child abuse
Axial CT without contrast of the brain shows normal density in the rounded top of the cerebellum (in the center of the left image) compared to the diffuse low-density throughout the cerebrum. There is obliteration of the basal cisterns and loss of the normal gray matter-white matter differentiation. There is also a small left sided high density extra-axial cresenteric fluid collection that tracks medially along the entire falx.