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

Zahl, S.M., Andersson, J., Wester, K. and Wikström, J. (2023), Neuroradiological findings in children with subdural hematoma and suspected abusive head trauma. Ann Child Neurol Soc, 1: 44-52. https://doi.org/10.1002/cns3.3

Abstract

Aim

Abusive head trauma (AHT) is often suspected in infants with subdural hematoma (SDH). Other neuroradiological findings have also been reported in assumed AHT, such as hypoxic–ischemic injury (HII), cortical vein thrombosis, and subarachnoid hemorrhage. The purpose of this study was to investigate neuroradiological and clinical findings in cases of suspected AHT.
Methods

Infants with SDH suspected to be caused by AHT, referred to the Swedish National Board of Forensic Medicine during the period 1994–2018, were considered for inclusion.
Results

Ninety-six cases were included, with 68% males. The proportions of infants born prematurely, and twins, were higher than in the normal population. Signs of “benign enlargement of the subarachnoid space” (BESS) were found in 36% and were associated with chronic SDH and nonacute symptoms. HII was found in 16% and was associated with subarachnoid hemorrhage and high mortality, but not traumatic findings. Clinical signs of increased intracranial pressure were associated with retinal hemorrhages.
Conclusion

This analysis indicates that infants with SDH investigated for AHT are a heterogeneous group with some cases associated with external signs of trauma and others with possibly nontraumatic etiologies. Infants with BESS are more likely to have chronic SDH and nonacute symptoms. Patients with HII often have serious/fatal outcomes, but are not associated with external signs of injury. The overrepresentation of males, premature infants, and twins is unexplained.

From the article:

Pre-existing BESS/chronic SDH

As recently shown in Andersson et al., a study on the same population, infants with chronic SDH had a male overrepresentation and were in comparison to acute SDH children more often premature, had lower mortality, and had more often increased head circumference. Andersson et al. also showed that there were clinical and/or radiological signs of BESS as a possible cause of the hemorrhage in a substantial portion of these children. None of the acute SDH infants had any sign of BESS. In addition, our results show that BESS is associated with nonacute symptoms, while skull fractures are associated with acute SDH. These findings further support the assumption launched by Andersson et al. of acute SDH and chronic SDH as two fundamentally different conditions...

Conclusion

In infants with SDH and suspected AHT, we found different groups of neuroradiological, epidemiological, and clinical findings, suggesting different etiologies.

Some infants have an obvious traumatic etiology; with acute SDH, skull fracture(s) or other signs of trauma, and AHT should then be suspected if a credible history of accidental trauma is not presented.

In some infants with chronic SDH, underlying BESS seems to represent a possible cause for the SDH.

Infants with hypoxic–ischemic injury seldom have external signs of trauma and have an even sex distribution. The overall high proportion of boys and premature infants may be related to different vulnerability factors and warrants further investigation, as also goes for the pathophysiology of hypoxic–ischemic injury in these infants.