The neuropathology of infant subdural haemorrhage

Macroscopic and histological examination of human bridging veins

In infantile abusive head injury (AHT), subdural haemorrhage (SDH) is commonly held to result from traumatic damage to bridging veins traversing from the surface of the brain to the dura and dural venous sinuses. However, there are limited published radiological or autopsy demonstrations of ruptured bridging veins and several authors also assert that bridging veins are too large to rupture due to the forces associated with AHT. There have been several studies on the size, locations and numbers of adult bridging veins and there is one small study of infant bridging veins. However, there are no microscopic studies of infant bridging veins and only a select few ultrastructural investigations of adult bridging veins. Hitherto, it has been assumed that bridging veins from infants and younger children will display the same anatomical characteristics as those in adulthood. At 19 neonatal, infant and young child post-mortem examinations, we macroscopically examined and sampled bridging veins for microscopy. We compared the histology of those samples with bridging veins from an older child and two adults. We demonstrate that adult bridging veins are usually surrounded by supportive meningeal tissue that appears to be lacking or minimally present around the bridging veins of younger children. Neonatal, infant and young children's veins had a free 'bridging' section. Neonatal and infant bridging veins had smaller diameter ranges and thinner walls (some only 5-7 µm) than those seen in older children and adults. Bridging vein walls contained both fine strands of elastic fibers and a more pronounced elastic lamina. The presence of an elastic lamina occurred more frequently in the older age groups These anatomical differences between the veins of adults and young children may help to explain apparent increased vulnerability of neonatal/infant bridging veins to the forces associated with a shaking-type traumatic event.

Traumatic Aneurysm Involving the Posterior Communicating Artery

Traumatic intracranial aneurysms (TICAs) are rare, accounting for less than 1% of all intracranial aneurysms. However, they are associated with a mortality rate of over 50%. The case presented herein focuses on a posterior communicating artery TICA caused by violent aggression. A 41-year-old man with massive subarachnoid hemorrhage (SAH), on admission to hospital, had a CT angiography that showed a ruptured left posterior communicating artery aneurysm with continuous blood loss and underwent neurosurgical cooling. The CT scan also showed fractures of the mandible, mastoid and left styloid process, as well as brain contusions caused by blows and kicks. Despite medical treatment and surgery, after four days, he died. The assault dynamics were recorded by a camera in the bar. The damage was caused by kicks to the neck and head. The forensic neuropathological examination showed the primary injury (SAH, subdural hemorrhage, cerebral contusions, head-neck fractures), as well as secondary damage following the attack (cerebral infarcts, edema, supratentorial hernia, midbrain hemorrhage). The coil was intact and well positioned. In this case, circumstantial information, medical records, and the type of injury could shed light on the mechanism of the production of a TICA. In addition, the CT angiography and histological investigations helped to distinguish a recent and traumatic aneurysm from a pre-existing one. Following precise steps, the study of aneurysms can be helpful in clarifying their traumatic origin even when the victim was taking drugs. The aim of this study is also to share the diagnostic process that we used in the forensic field for the assessment of suspected traumatic aneurysms.

Comparison of abusive head trauma versus non-inflicted subdural haematoma in infants: A retrospective cohort study

OBJECTIVES

To compare the characteristics of subdural haematoma (SDH) in children under the age of 2 years, between inflicted, otherwise known as abusive head trauma (AHT), and non-inflicted aetiologies.

METHODS

This was a retrospective cohort study of 37 cases of SDH in children under the age of 2 years presenting to the ED at an Australian tertiary children's hospital between January 2009 and December 2012 and been assessed by the Child Protection Unit. SDH aetiology was classified into AHT and non-inflicted groups, based on child protection interagency outcome. These groups were compared to determine clinical associations with AHT.

RESULTS

Of the 37 infants with SDH, 20 cases were deemed due to AHT, whereas 17 cases were determined to be non-inflicted SDH (15 cases due to accidental trauma and two cases due to congenital benign enlargement of the subarachnoid space). SDH due to AHT was associated with antenatal maternal drug use, previous Department of Child Safety involvement, delayed presentation, history of seizures, floppiness or altered level of consciousness; extracranial findings of fractures, bruising or retinal haemorrhages; radiological findings of >5 mm depth, bilateral, inter-hemispheric blood, posterior fossa blood and diffusion restriction; and outcomes of death or permanent disability. Non-inflicted SDH was associated with witnessed injury, falls and scalp haematoma on imaging.

CONCLUSIONS

Infant SDH due to AHT accounts for high mortality and morbidity. Early identification of these patients in the ED with referral to specialised units that investigate for potential child abuse is essential.

The dural vascular plexus in subdural hematoma: Illustration through a case of dural arteriovenous fistula

Background

The initiation of chronic subdural hematoma (cSDH) is traditionally explained by rupture of bridging veins. Recent descriptions of the embryology and anatomy of the meninges and their vascularization, however, point to the dural vascular plexus (DVP) as a plausible origin of cSDH. This dural plexus is supplied by meningeal arteries. Their endovascular occlusion is efficient in cSDH treatment. Dural arteriovenous fistulae (dAVF) may also present with subdural hematoma.

Case Description

A 65-year-old female patient presented with parietal parasagittal dAVF and bilateral cSDH requiring surgical disconnection followed by complete clinical and imaging resolution of dAVF and cSDH.

Conclusion

In common cSDH, pressure in the DVP may be normal and subdural bleeding may occur due to mechanical traction on the DVP. In the setting of dAVF, it may be the increase in pressure due to the fistula, within the DVP, that causes subdural hematoma. The DVP, supplied by meningeal arteries, thus not only allows for convergent pathophysiological explanation of subdural bleeding in both cSDH and dAVF but may also be the actual target of the emergent endovascular treatment of cSDH trough meningeal artery embolization.

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

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.

Answer to Squier et al

The author responds to critics formulated by W Squier regarding our paper "The legal challenges to the diagnosis of shaken baby syndrome Or: how to counter 12 common fake news.

Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma

Aim

Thrombosis of bridging veins has been suggested to be a marker of bridging vein rupture, and thus AHT, in infants with subdural haematoma.

Methods

This is a non‐systematic review based on Pubmed search, secondary reference tracking and authors’ own article collections.

Results

Radiological studies asserting that imaging signs of cortical vein thrombosis were indicative of traumatic bridging vein rupture were unreliable as they lacked pathological verification of either thrombosis or rupture, and paid little regard to medical conditions other than trauma. Autopsy attempts at confirmation of ruptured bridging veins as the origin of SDH were fraught with difficulty. Moreover, microscopic anatomy demonstrated alternative non‐traumatic sources of a clot in or around bridging veins. Objective pathological observations did not support the hypothesis that a radiological finding of bridging vein thrombosis was the result of traumatic rupture by AHT. No biomechanical models have produced reliable and reproducible data to demonstrate that shaking alone can be a cause of bridging vein rupture.

Conclusion

There is no conclusive evidence supporting the hypothesis that diagnostic imaging showing thrombosed bridging veins in infants correlates with bridging vein rupture. Hence, there is no literature support for the use of thrombosis as a marker for AHT.

Incidental findings on brain MR imaging of asymptomatic term neonates in the Developing Human Connectome Project

BACKGROUND

Interpretation of incidental findings on term neonatal MRI brain imaging can be challenging as there is a paucity of published normative data on asymptomatic term neonates. Reporting radiologists and clinicians need to be familiar with these incidental findings to avoid over-investigation and misinterpretation particularly in relation to neurodevelopmental outcome. This study aimed to determine the prevalence of incidental findings in a large group of asymptomatic term neonates participating in the Developing Human Connectome Project (dHCP) who were invited for neurodevelopmental assessment at 18 months.

METHODS

We retrospectively reviewed MRI brain scans performed on 500 term neonates enrolled in the dHCP study between 2015 and 2019 with normal clinical examination. We reviewed the results of the Bayley Scales of Infant and Toddler Development (Bayley III) applied to participants who attended for neurodevelopmental follow-up at 18 months. Scores considered "delayed" if <70 on language, cognitive or motor scales.

FINDINGS

Incidental findings were observed in 47% of term infants. Acute cerebral infarcts were incidentally noted in five neonates (1%). More common incidental findings included punctate white matter lesions (PWMLs) (12%) and caudothalamic subependymal cysts (10%). The most frequent incidental finding was intracranial haemorrhage (25%), particularly subdural haemorrhage (SDH). SDH and PWMLs were more common in infants delivered with ventouse-assistance versus other delivery methods.Neurodevelopmental results were available on 386/500 (77%). 14 infants had a language score < 70 (2 SD below the mean). Of the 386 infants with neurodevelopmental follow up at 18 months, group differences in motor and language scores between infants with and without incidental findings were not significant (p = 0·17 and p = 0·97 respectively). Group differences in cognitive scores at 18 months between infants with (median (interquartile range) -100 (95-105)) and without (100 (95-110)) incidental findings were of small effect size to suggest clinical significance (Cliff's d = 0·15; p<0·05).

INTERPRETATION

Incidental findings are relatively common on brain MRI in asymptomatic term neonates, majority are clinically insignificant with normal neurodevelopment at 18 months.

FUNDING

This work was supported by the European Research Council under the European Union's Seventh Framework Programme (FP7/20072013/ERC grant agreement no. [319456] dHCP project), by core funding from the Wellcome/EPSRC Centre for Medical Engineering [WT203148/Z/16/Z] and by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London and/or the NIHR Clinical Research Facility. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Macrocephaly and subdural collections

Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.

Spinal cord injury as an indicator of abuse in forensic assessment of abusive head trauma (AHT)

Abusive head trauma (AHT) in children is notoriously one of the most challenging diagnoses for the forensic pathologist. The pathological “triad”, a combination of intracranial subdural haematoma, cerebral oedema with hypoxic-ischaemic changes and retinal haemorrhages, is frequently argued to be insufficient to support a corroborated verdict of abuse. Data from all available English-language scientific literature involving radiological and neuropathological spinal cord examination is reviewed here in order to assess the contribution of spinal cord changes in differentiating abusive from accidental head trauma. In agreement with the statistically proven association between spinal subdural haemorrhage (SDH) and abuse (Choudhary et al. in Radiology 262:216–223, 2012), spinal blood collection proved to be the most indicative finding related to abusive aetiology. The incidence of spinal blood collection is as much as 44–48% when all the spinal cord levels are analysed as opposed to just 0–18% when the assessment is performed at cervical level only, in agreement with the evidence of the most frequent spinal SDH location at thoracolumbar rather than cervical level. In this review, the source of spinal cord blood collection and how the age of the child relates to the position of spinal cord lesions is also discussed. We concluded that the ante mortem MRI examination and post mortem examination of whole-length spinal cord is of fundamental interest for the assessment of abuse in the forensic setting.

[Bridging vein injuries in shaken baby syndrome : Forensic-radiological meta-analysis with special focus on the tadpole sign]

Shaken baby syndrome is a common variant of the abusive head trauma in infants and toddlers and is still subject of intensive research. In recent years, a number of radiological studies on the diagnostic and forensic relevance of injured bridging veins were conducted using different imaging modalities. The present article will give an overview on the current state of research in this field and will discuss the forensic implications. The meta-analysis of the seven currently existing studies revealed that injuries of the bridging veins and bridging vein thromboses, respectively, frequently appear as rounded, enlarged, and/or tubular structures. The "tadpole sign" may serve as a valuable tool for the identification of these formations. Especially, T2*/SWI (susceptibility-weighted imaging) sequences allow for good detectability of these lesions and should always be generated when abusive head trauma is suspected. In conclusion, it can be recommended that the presence of radiologically detectable bridging vein injuries should give reason to search for other manifestations of physical child abuse.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

AIM

Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants.

METHODS

Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature.

RESULTS

Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children.

CONCLUSION

Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

Prevalence and Risk Factors of Incidental Findings in Brain MRIs of Healthy Neonates-The FinnBrain Birth Cohort Study

Background: Birth is a traumatic event with molding forces directed to the fetal skull, which may result in intracranial hemorrhages. However, the knowledge on prevalence and risk factors of incidental brain magnetic resonance imaging (MRI) findings in infants is still inconclusive.

Methods: The prevalence and nature of incidental MRI findings were assessed in a birth cohort of 175 asymptomatic infants. The role of delivery method as well as other potential risk factors for intracranial hemorrhages were evaluated. The infants underwent 3T MRI at the age of 2–5 weeks, and the neurological status of the infants with an incidental finding was evaluated by a pediatric neurologist. Information on the delivery method, duration of delivery, parity, used anesthesia, oxytocin induction, and Apgar score was gathered to evaluate their association with the prevalence of hemorrhages.

Results: Incidental intracranial hemorrhages were detected in 12 infants (6.9%), all following spontaneous or assisted vaginal delivery. Vacuum-assistance was found to be a risk factor for subdural hemorrhages with an odds ratio (OR) of 4.7 (95% CI [1.18; 18.9], p = 0.032). All infants were evaluated to develop normally by their clinical status.

Conclusions: Incidental intracranial hemorrhages are relatively common among infants born by vaginal delivery. They are often of little clinical significance within the first years of life and have unlikely consequences for later neurodevelopment either. Despite their benign character, investigators should be prepared to share this information with parents competently as the findings can cause parental anxiety, and especially as the popularity of MRI as a research tool is increasing.

Traumatic Brain Injury: A Forensic Approach: A Literature Review

Traumatic brain injury (TBI) is the principal cause of invalidity and death in the population under 45 years of age worldwide. This mini-review aims to systematize the forensic approach in neuropathological studies, highlighting the proper elements to be noted during external, radiological, autoptical, and histological examinations with particular attention paid to immunohistochemistry and molecular biology. In the light of the results of this mini-review, an accurate forensic approach can be considered mandatory in the examination of suspected TBI with medico-legal importance, in order to gather all the possible evidence to corroborate the diagnosis of a lesion that may have caused, or contributed to, death. From this point of view, only the use of an evidence-based protocol can reach a suitable diagnosis, especially in those cases in which there are other neuropathological conditions (ischemia, neurodegeneration, neuro-inflammation, dementia) that may have played a role in death. This is even more relevant when corpses, in an advanced state of decomposition, are studied, where the radiological, macroscopic and histological analyses fail to give meaningful answers. In these cases, immune-histochemical and molecular biology diagnostics are of fundamental importance and a forensic neuropathologist has to know them. Particularly, MiRNAs are promising biomarkers for TBI both for brain damage identification and for medico-legal aspects, even if further investigations are required to validate the first experimental studies. In the same way, the genetic substrate should be examined during any forensic examination, considering its importance in the outcome of TBI.

Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study

BACKGROUND AND AIMS

Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out-of-home care. The objective of this study was to analyse infants placed in out-of-home care in Sweden by incidence, medical diagnoses, and perinatal factors.

METHODS

This was a population-based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out-of-home care categories: (a) "Problems Related to Social Environment/Upbringing", (b) "Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture", and (c) "SDH, RH, rib fracture, or long bone fracture." As a reference population, we randomly selected infants without medical diagnoses born the same year.

RESULTS

Overall incidence of out-of-home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out-of-home care, children in category (c), "SDH, RH, rib fracture, or long bone fracture", had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08-2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32-0.75) and a smoker (aOR 0.60; 95% CI, 0.37-0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small-for-gestational age (5.2% versus 2.1%).

CONCLUSION

SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out-of-home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.

Infant abuse diagnosis associated with abusive head trauma criteria: incidence increase due to overdiagnosis?

Background

The hypothesis of this study is that the diagnosis of infant abuse is associated with criteria for shaken baby syndrome (SBS)/abusive head trauma (AHT), and that that changes in incidence of abuse diagnosis in infants may be due to increased awareness of SBS/AHT criteria.

Methods

This was a population-based register study. Setting: Register study using the Swedish Patient Register, Medical Birth Register, and Cause of Death Register. The diagnosis of infant abuse was based on the International Classification of Diseases, 9th and 10th revision. Participants: All children born in Sweden during 1987-2014 with a follow-up until 1 year of age (N = 2 868 933). SBS/AHT criteria: subdural haemorrhage, cerebral contusion, skull fracture, convulsions, retinal haemorrhage, fractures rib and long bones. Outcomes: Incidence, rate ratios, aetiologic fractions and Probit regression analysis.

Results

Diagnosis of infant abuse was strongly associated with SBS/AHT criteria, but not risk exposure as region, foreign-born mother, being born preterm, multiple birth and small for gestational age. The incidence of infant abuse has increased tenfold in Sweden since the 1990s and has doubled since 2008, from 12.0 per 100 000 infants during 1997-2007 to 26.5/100 000 during 2008-2014, with pronounced regional disparities.

Conclusions

Diagnosis of infant abuse is related to SBS/AHT criteria. The increase in incidence coincides with increased medical preparedness to make a diagnosis of SBS/AHT. Hidden statistics and a real increase in abuse are less plausible. Whether the increase is due to overdiagnosis cannot be answered with certainty, but the possibility raises ethical and medico-legal concerns.

Non-Traumatic Acute Subdural Hemorrhage Due To Cranial Venous Hypertension

Acute subdural hemorrhage is typically associated with a history of head trauma, and as such it is a finding with significant potential medicolegal consequences. In this article, 37 adult and post-infantile pediatric sudden death autopsy cases with small volume ("thin film" or "smear") acute subdural hemorrhage are presented-in which there is either no further evidence of head trauma or only features of minor head injury. The possible underlying pathophysiological mechanisms are explored, and it is concluded that a common thread in many of these cases is likely to have been cranial venous hypertension at around the time of death. These findings may have implications in instances where small volume subdural hemorrhage is identified in the absence of other evidence of significant head injury.

Early Postoperative Morbidity After Chronic Subdural Hematoma: Predictive Usefulness of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity, American College of Surgeons National Surgical Quality Improvement Program, and American Society of Anesthesiologists Grade in a Prospective Cohort

BACKGROUND

Although chronic subdural hematoma (CSDH) is generally benign, long-term survival (LTS) after CSDH is poor in a significant subgroup. This dichotomy has been compared to fractured neck of femur. However, although early postoperative mortality (within 30 days of CSDH) is well recorded with CSDH and similar to fractured neck of femur (4%-8%), scant accurate data exist regarding early postoperative morbidity (POMB). POMB, which prolongs length of stay (LOS) after major nonneurosurgery, is associated with decreased LTS. One recent CSDH study suggested a POMB standard of 10% i.e., notably less than with fractured neck of femur (45%).

METHODS

POMB was recorded in a novel prospective single-center cohort after CSDH. The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity), American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) score, and American Society of Anesthesiologists (ASA) grade were assessed as tools for potentially predicting POMB. Receiver operating characteristic (ROC) curves were calculated.

RESULTS

Early postoperative mortality (within 30 days of CSDH) occurred in 3 of 114 patients (3%). Seventy-one POMB events occurred in 54 of 114 patients (47%), with 27 of 54 (50%) having a Clavien-Dindo grade ≥2. Most POMB was neurologic (n = 47/71, 66%). Age (P = 0.01), Glasgow Coma Scale (GCS) score (P = 0.001), Markwalder grade (P = 0.01), hypertension (P = 0.047), and/or ≥1 preexistent comorbidity (P = 0.041) were predictive. LOS (P = 0.01) and discharge modified Rankin Scale score (P < 0.001) were significantly associated. Predicted and observed POMB with POSSUM were significantly disparate (χ² = 15.23; P = 0.001): POSSUM area under ROC (AUROC = 0.611) was also nondiscriminatory. ACS-NSQIP (χ² = 18.51; P < 0.001; AUROC = 0.629) and ASA grades (P = 0.25) were also nonpredictive.

CONCLUSIONS

POMB was frequently disabling, mostly neurologic, and as frequent and diverse as with fractured neck of femur. POMB was significantly correlated with LOS and discharge modified Rankin Scale score. Surprisingly, POSSUM, ACS-NSQIP, and ASA grades were not predictive and would not aid consent. Simple parameters (age, Glasgow Coma Scale, Markwalder grade, hypertension, and/or ≥1 other comorbidity) were instead predictive. Longitudinal follow-up will determine whether POMB affects LTS. CSDH, like fractured neck of femur, is distinct.

Understanding Subdural Collections in Pediatric Abusive Head Trauma

Life-threatening physical abuse of infants and toddlers is frequently correlated with head injuries. A common variant of the abusive head trauma is the shaken baby syndrome. The present review article sheds light on subdural collections in children with abusive head trauma and aims at providing a recent knowledge base for various medical disciplines involved in diagnostic procedures and legal proceedings. To this end, the different subdural collection entities are presented and illustrated. The pathophysiologic background is explained. Differential and age-diagnostic aspects are discussed and summarized by tabular and graphic overviews. Two problematic constellations frequently occurring during initial CT investigations are evaluated: A mixed-density subdural collection does not prove repeated trauma, and hypodense subdural collections are not synonymous with chronicity. The neuroradiologic analysis and assessment of subdural collections may decisively contribute to answering differential diagnostic and forensic questions. In addition to more reference data, a harmonization of terminology and methodology is urgently needed, especially with respect to age-diagnostic aspects.

Ocular and Intracranial MR Imaging Findings in Abusive Head Trauma

Abusive head trauma (AHT) is a form of inflicted head injury. AHT is more frequent in 2-year-old or younger children. It is an important cause of neurological impairment and the major cause of death from head trauma in this age group. Brain magnetic resonance imaging allows the depiction of retinal hemorrhages, injured bridging veins, and identifying and localizing extra- and intra-axial bleeds, contusions, lacerations, and strokes. The diagnosis of AHT is a multidisciplinary team effort which includes a careful evaluation of social, clinical, laboratory, and radiological findings. Notwithstanding, the introduction in the current clinical practice of high-resolution techniques is adding forensic evidence to the recognition of AHT.

Epidemiology of subdural haemorrhage during infancy: A population-based register study

Objectives

To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse.

Methods

A Swedish population-based register study comprising infants born between 1997 and 2014, 0–1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10^th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0–6 and 7–365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis.

Results

Incidence of SDH was 16·5 per 100 000 infants (n = 306). Median age was 2·5 months. For infants older than one week, the median age was 3·5 months. Case fatality was 6·5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0–6 days, having a perinatal risk profile. For infants aged 7–365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age.

Conclusions

The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.

Histology of Brain Trauma and Hypoxia-Ischemia

Forensic pathologists encounter hypoxic-ischemic (HI) brain damage or traumatic brain injuries (TBI) on an almost daily basis. Evaluation of the findings guides decisions regarding cause and manner of death. When there are gross findings of brain trauma, the cause of death is often obvious. However, microscopic evaluation should be used to augment the macroscopic diagnoses. Histology can be used to seek evidence for TBI in the absence of gross findings, e.g., in the context of reported or suspected TBI. Estimating the survival interval after an insult is often of medicolegal interest; this requires targeted tissue sampling and careful histologic evaluation. Retained tissue blocks serve as forensic evidence and also provide invaluable teaching and research material. In certain contexts, histology can be used to demonstrate nontraumatic causes of seemingly traumatic lesions. Macroscopic and histologic findings of brain trauma can be confounded by concomitant HI brain injury when an individual survives temporarily after TBI. Here we review the histologic approaches for evaluating TBI, hemorrhage, and HI brain injury. Amyloid precursor protein (APP) immunohistochemistry is helpful for identifying damaged axons, but patterns of damage cannot unambiguously distinguish TBI from HI. The evolution of hemorrhagic lesions will be discussed in detail; however, timing of any lesion is at best approximate. It is important to recognize artifactual changes (e.g., dark neurons) that can resemble HI damage. Despite the shortcomings, histology is a critical adjunct to the gross examination of brains.

A systematic autopsy survey of human infant bridging veins

In the first years of life, subdural haemorrhage (SDH) within the cranial cavity can occur through accidental and non-accidental mechanisms as well as from birth-related injury. This type of bleeding is the most common finding in victims of abusive head trauma (AHT). Historically, the most frequent cause of SDHs in infancy is suggested to be traumatic damage to bridging veins traversing from the brain to the dural membrane. However, several alternative hypotheses have been suggested for the cause and origin of subdural bleeding. It has also been suggested by some that bridging veins are too large to rupture through the forces associated with AHT. To date, there have been no systematic anatomical studies on infant bridging veins. During 43 neonatal, infant and young child post-mortem examinations, we have mapped the locations and numbers of bridging veins onto a 3D model of the surface of a representative infant brain. We have also recorded the in situ diameter of 79 bridging veins from two neonatal, one infant and two young children at post-mortem examination. Large numbers of veins, both distant from and directly entering the dural venous sinuses, were discovered travelling between the brain and dural membrane, with the mean number of veins per brain being 54.1 and the largest number recorded as 94. The mean diameter of the bridging veins was 0.93 mm, with measurements ranging from 0.05 to 3.07 mm. These data demonstrate that some veins are extremely small and subjectively, and they appear to be delicate. Characterisation of infant bridging veins will contribute to the current understanding of potential vascular sources of subdural bleeding and could also be used to further develop computational models of infant head injury.

Intracranial hemorrhage in term neonates

BACKGROUND

Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates; currently, ICH is more frequently diagnosed because of improved neuroimaging techniques.

PURPOSE

The study aims to evaluate the clinical characteristics and neuroimaging data (pattern, size, distribution) of neonatal ICH.

METHODS

We reviewed MRI data from July 2004 to June 2015 for 42 term neonates with ICH who were less than 1 month old. We recorded clinical data and manifestations, mode of delivery, Apgar score at 1 and 5 min, associated hypoxic insult, birth trauma, neurological symptoms, EEG results, extent and site of hemorrhage, neurosurgical intervention, and developmental outcomes. The clinical outcome was determined for 27 neonates. Risk factors were assessed in relation to ICH.

RESULTS

A total of 42 neonates who presented with ICH underwent MR imaging 2 to 22 days postnatally (mean age 9.3 days). The majority of clinical symptoms were present in patients within the first 24 h of life (n = 31), but symptoms appeared until day 10 postnatally (mean 4.9 days, n = 11). Seizure or seizure-like activity was the most common presenting symptom (17/42, 40.5%), with apnea seen in another seven infants (7/42, 16.7%). The majority of infants had a normal prenatal course. Two patients had antenatally detected hydrocephalus. Ten had infratentorial hemorrhage, and two had supratentorial hemorrhage. A total of 30 infants had a combination of infratentorial and supratentorial hemorrhage. Subdural hemorrhage (SDH) was the most common type of hemorrhage (40/42, 95.2%), followed by nine cases of parenchymal hemorrhage, seven of subarachnoid hemorrhage, three of germinal matrix hemorrhage (GMH), and one of epidural hemorrhage (EDH). A total of 16 infants had two or more types of hemorrhage. SDH was identified along the tentorium (n = 38) as well as over the cerebellar hemispheres (n = 39), along the interhemispheric fissure (n = 10), and over the occipital (n = 13) or parietooccipital (n = 11) lobes. Intraparenchymal hemorrhage involved either the frontal (n = 4), parietal (n = 3), or cerebellar (n = 2) lobes. Traumatic delivery was suspected in 20 patients (47.6%), and perinatal asphyxia was present in 21 patients (50.0%). A low Apgar score at 5 min and a history of perinatal asphyxia were the factors that most predicted poor clinical outcomes (n = 12/27). Logistic regression analysis revealed that a history of perinatal asphyxia resulted in poor outcomes. No patients died. One infant required burr hole drainage of a right parietal EDH, one infant needed a subcutaneous reservoir, and three infants required a ventriculoperitoneal shunt for obstructive hydrocephalus.

CONCLUSION

SDH was the most common type of ICH in term infants. Combined supratentorial and infratentorial hemorrhage was more common than isolated infratentorial hemorrhage in these infants. A total of 44.4% of patients had poor outcomes, with perinatal asphyxia the most common statistically significant cause.

Evaluation of the Hypothesis That Choking/ALTE May Mimic Abusive Head Trauma

OBJECTIVE

Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH.

METHODS

We performed a 5-year retrospective case-control study of children <2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries.

RESULTS

Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury.

CONCLUSIONS

ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.

Post-mortem imaging of the infant and perinatal dura mater and superior sagittal sinus using optical coherence tomography

Infants and young children are likely to present with subdural haemorrhage (SDH) if they are the victims of abusive head trauma. In these cases, the most accepted theory for the source of bleeding is the bridging veins traversing from the surface of the brain to the dura mater. However, some have suggested that SDH may result from leakage of blood from a dural vascular plexus. As post-mortem examination of the bridging veins and dura is challenging, and imaging modalities such as magnetic resonance and computed tomography do not have the resolution capabilities to image small blood vessels, we have trialled the use of intravascular and benchtop optical coherence tomography (OCT) systems for imaging from within the superior sagittal sinus (SSS) and through the dura during five infant/perinatal autopsies. Numerous vessel-like structures were identified using both OCT systems. Measurements taken with the intravascular rotational system indicate that the approximate median diameters of blood vessels entering anterior and posterior segments of the SSS were 110 μm (range 70 to 670 μm, n = 21) and 125 μm (range 70 to 740 μm, n = 23), respectively. For blood vessels close to the wall of the SSS, the median diameters for anterior and posterior segments of the SSS were 80 μm (range 40 to 170 μm, n = 25) and 90 μm (range 30 to 150 μm), respectively. Detailed characterisation of the dural vasculature is important to aid understanding of the source of SDH. High resolution 3-dimensional reconstructions of the infant dural vasculature may be possible with further development of OCT systems.

Membrane Surface Area to Volume Ratio in Chronic Subdural Hematomas: Critical Size and Potential Postoperative Target

BACKGROUND

It is unknown why some chronic subdural hematomas (CSDHs) grow and require surgery, whereas others spontaneously resolve. Although a relatively small CSDH volume (V) reduction may induce resolution, V percent reduction is often unreliable in predicting resolution. Although CSDHs evolve distinctive inner neomembranes and outer neomembranes (OMs), the OM likely dominates the dynamic growth-resorption equilibrium. If other factors remain constant, one previous hypothesis is that resorption could fail as the surface area (SA) to V ratio decreases when CSDHs exceed a critical size. We aimed to identify a critical size and an ideal target, which implies resolution without recurrence.

METHODS

Three-dimensional computed tomography CSDH SA to V ratios were obtained using computer software to compare CSDH SA to V between cases requiring surgery (surgical) and cases managed conservatively with spontaneous resolution (nonsurgical).

RESULTS

Data were obtained in 45 patients (surgical: n = 28; nonsurgical: n = 17). CSDH risk factors did not significantly differ between surgical and nonsurgical cases. Surgical V was 2.5× the nonsurgical V (119.9 ± 33.1 mL vs. 48.4 ± 27.4 mL, respectively; P < 0.0001). Surgical total SA was 1.4× nonsurgical SA (256.63 ± 70.65 cm² vs. 187.67 ± 77.72 cm², respectively; P = 0.004). Surgical total SA to V ratio was approximately one half that of nonsurgical SA to V ratio (2.14 ± 0.90 mL^-1 vs. 3.88±1.22 mL^-1, respectively; P < 0.0001). Surgical OM SA (SA_OM) was 120.63 ± 52 cm², and nonsurgical SA_OM was 94.10 ± 41 cm² (P < 0.0001). Nonsurgical SA_OM to V ratio was 1.94 mL^-1, whereas surgical SA_OM to V ratio was 1.005 mL^-1 (i.e., surgical SA_OM ≈ V).

CONCLUSIONS

Because surgical total SA to V ratio was ≈2:1, one neomembrane may indeed dominate the dynamic growth-resorption equilibrium. CSDH critical size therefore appears to be when SA_OM ≈ V, which is intuitive. Practically, subtotal CSDH evacuation which approximately doubles total SA to V ratio or SA_OM to V ratio implies CSDH resolution without recurrence. This could guide subdural drain removal timing, discharge, or transfer. Prospective validation studies are required.

The Neurocritical and Neurosurgical Care of Subdural Hematomas

Subdural hematomas (SDHs), though frequently grouped together, can result from a variety of different etiologies, and therefore many different subtypes exist. Moreover, the high incidence of these lesions in the neurocritical care settings behooves practitioners to have a firm grasp on their diagnosis and management. We present here a review of SDHs, with an emphasis on how different subtypes of SDHs differ from one another and with discussion of their medical and surgical management in the neurocritical care setting. In this paper, we discuss considerations for acute, subacute, and chronic SDHs and how presentation and management may change in both the elderly and pediatric populations. We discuss SDHs that arise in the setting of anticoagulation, those that arise in the setting of active cerebrospinal fluid diversion, and those that are recurrent and recalcitrant to initial surgical evacuation. Management steps reviewed include detailed discussion of initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring. Direct surgical management options are reviewed, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems. SDHs are a common finding in the neurocritical care setting and have a diverse set of presentations. With a better understanding of the fundamental differences between subtypes of SDHs, critical care practitioners can better tailor their management of both the patient's intracranial and multi-systemic pathologies.

Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms

The cause of death in infants who die suddenly and unexpectedly (sudden unexpected death in infancy [SUDI]) remains a diagnostic challenge. Some infants have identified diseases (explained SUDI); those without explanation are called sudden infant death syndrome (SIDS). Demographic data indicate subgroups among SUDI and SIDS cases, such as unsafe sleeping and apparent life-threatening events. Infants dying suddenly with retinal and dural bleeding are often classified as abused, but in many there is no evidence of trauma. Demographic features suggest that they may represent a further subgroup of SUDI. This review examines the neuropathological hypotheses to explain SIDS and highlights the interaction of infant oxygen-conserving reflexes with the brainstem networks considered responsible for SIDS. We consider sex- and age-specific vulnerabilities related to dural bleeding and how sensitization of the dural innervation by bleeding may influence these reflexes, potentially leading to collapse or even death after otherwise trivial insults.

External drains versus no drains after burr-hole evacuation for the treatment of chronic subdural haematoma in adults

BACKGROUND

Chronic subdural haematoma (CSDH) is one of the most common types of intracranial haematoma, and often occurs in older people. Burr-hole craniostomy, which is an evacuation through one or two burr holes drilled over the site of the haematoma, has been widely accepted as the most effective way to manage CSDH. Recurrences are a major problem and need reoperation, sometimes repeatedly.

OBJECTIVES

To assess the effects and safety of the use of external drains versus no drains after burr-hole evacuation for the treatment of CSDH in adults.

SEARCH METHODS

We ran our first search on 27 November 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE (OvidSP), Embase Classic+Embase (OvidSP), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S and CPSI-SSH), Chinese databases, and clinical trials registers, and screened reference lists. In compliance with the MECIR conduct standard 37, the Cochrane Injuries Group Information Specialist ran an update search within 12 months of publication (25 April 2016). We have screened these results but not incorporated the findings into the current review; as a result of the update search, one trial is awaiting classification.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared external subdural drains with no drains after burr-hole evacuation for the treatment of CSDH in adults.

DATA COLLECTION AND ANALYSIS

Two review authors identified potential articles from the literature search, extracted data independently using a data extraction form and assessed risk of bias using the Cochrane 'Risk of bias' tool. For dichotomous data, where statistical heterogeneity was low, we calculated summary risk ratios with 95% confidence intervals using a fixed-effect model.

MAIN RESULTS

Nine RCTs, including a total of 968 participants, reported outcomes specified by this review. Only one RCT reported the use of an adequate method of allocation concealment; this trial was a large, single-centre, high quality study and was adequately reported. All included trials reported a reduced recurrence of CSDH with external subdural drains. We found a significant reduction in the risk of recurrence with subdural drains (RR 0.45, 95% CI 0.32 to 0.61, I(2) = 38%; 9 studies, 968 participants; moderate-quality evidence). There was no strong evidence of any increase in complications (RR 1.15; 95% CI 0.77 to 1.72, I(2) = 0%; 7 studies, 710 participants; low-quality evidence), mortality (RR 0.78, 95% CI 0.45 to 1.33, I(2) = 22%; 5 studies, 539 participants; low-quality evidence), or poor functional outcome (which included deaths) (RR 0.68, 95% CI 0.44 to 1.05, I(2) = 31%; 5 studies, 490 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

There is some evidence that postoperative drainage is effective in reducing the symptomatic recurrence of CSDH. Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Due to the low quality of the evidence for the secondary outcomes, the effect of drainage on the occurrence of surgical complications, mortality and poor functional outcome is uncertain. This uncertainty can be clarified with data from high-quality studies which may be conducted in the future. There is no strong evidence of any increase in complications when drains are used.

Exploring the controversy in child abuse pediatrics and false accusations of abuse

There is a controversy in child abuse pediatrics between an established corps of child abuse pediatricians aligned with hospital colleagues and law enforcement, and a multi-specialty challenger group of doctors and other medical professionals working with public interest lawyers. The latter group questions the scientific validity of the core beliefs of child abuse pediatricians and believes that there are a substantial number of false accusations of abuse occurring. An unproven primary hypothesis, crafted around 1975 by a small group of pediatricians with an interest in child abuse, lies at the foundation of child abuse pediatrics. With no scientific study, it was hypothesized that subdural hemorrhage (SDH) and retinal hemorrhage (RH) were diagnostic of shaking abuse. That hypothesis became the so-called "shaken baby syndrome." Through the period 1975-1985, in a coordinated manner, these child abuse specialists coalesced under the American Academy of Pediatrics and began working with district attorneys and social workers, informing them of the ways in which their hypothesis could be applied to prosecutions of child abuse and life-altering social service interventions. In a legal context, using then-prevailing evidentiary rules which treated scientific expert testimony as valid if it was "generally accepted" in the field, they represented falsely that there was general acceptance of their hypothesis and therefore it was valid science. As the ability to convict based on this unproven prime hypothesis (SDH and RH equals abuse) increased, some defense attorneys were professionally compelled by their own doubts to reach out to experts from other fields with experience with SDH and RH, trauma, and biomechanics, for second opinions. Medical and legal challenges to the established thinking soon emerged, based on both old and new evidenced-based literature. As the intensity of the controversy increased, the probability of false accusation became more apparent and the need to address the issue more pressing. Since false accusations of child abuse are themselves abusive, efforts to eliminate such false accusations must continue.

A blackhole over brain: Interdural hematoma - A challenging diagnosis

Hematoma in between two dura leaves, named as 'interdural hematoma', is a very rare entity in adulthood. Interdural hematoma may emerge spontaneously or secondary to coagulopathies. A 61-year-old male patient, who had a medical history of alcoholic cirrhosis, presented with interdural hematoma. The case has been discussed with a literature review about diagnostic and therapeutic approaches in this pathology.

Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications

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.

Acute enlargement of subdural hygroma due to subdural hemorrhage in a victim of child abuse

An 11-month-old female baby was found dead by her mother. Cranial postmortem CT prior to the forensic autopsy showed dilatation of bilateral extra-axial spaces and ventricles. The autopsy revealed a new linear fracture of the left parietal bone and occipital bone, and a healed linear fracture of the right parietal bone and occipital bone like a mirror image of the left one as well. Intracranially, 230ml of subdural fluid were collected, which was mixed with blood. There was a fresh hemorrhage around a bridging vein of the left parietal lobe and the dura mater. Moreover, the outer side of the cerebrum and the inner side of the dura mater were covered by a thin membrane, which mater might have been previously formed because of being positive for Fe-staining and anti-CD68 antibody. A subdural hematoma might have been developed when the right side of the skull was previously fractured, which was transformed into a subdural hygroma. Subsequently, it is likely that, after the left side fracture of the skull occurred, the subdural hygroma rapidly enlarged due to hemorrhaging from the bridging vein, which resulted in intracranial hypertension, because microbleeding was detected in the brain stem. Accordingly, we diagnosed the cause and manner of death as intracranial hypertension due to subdural hemorrhage in subdural hygroma, and homicide, including child abuse, respectively.

Imaging of bridging vein thrombosis in infants with abusive head trauma: the "Tadpole Sign"

OBJECTIVES

Abusive head trauma (AHT) in infants is usually diagnosed using a multi-disciplinary approach by investigating the circumstances and identifying morphological indicators, for example, subdural hematomas (SDHs), subdural hygromas (SDHys), retinal haemorrhages and encephalopathy. The present morphological study investigates the incidence, radiological characteristics and non-radiological co-factors of bridging vein thrombosis (BVT) in infants with AHT.

METHODS

From 2002 to 2013, computed tomography (CT) and magnetic resonance imaging (MRI) material of 628 infants aged 0-2 years were analysed retrospectively. If available, medicolegal expert opinions were additionally considered. Cases with SDHs and/or SDHys were identified and systematically evaluated as to the presence and characteristics of BVT.

RESULTS

SDHs and/or SDHys were present in 29 of the 81 cases exhibiting morphological abnormalities in the initial CT. Among these, 11 cases (40%) had BVT (mean age = 5.0 months). BVT could be best depicted in the T1-weighted spin echo and T2*/susceptibility-weighted MRI. In one case, BVT could be depicted indirectly using time-of-flight MR venography. The predominant (73%) BVT shape was found to be tadpole-like ("Tadpole Sign").

CONCLUSIONS

In the absence of appropriate accidental trauma, BVT appears to be a strong indicator of AHT. Therefore, the BVT/Tadpole Sign represents compelling cause to search for other signs of AHT.

KEY POINTS

• BVT is an excellent indicator of AHT in SDH/SDHy cases. • Accidental trauma must be ruled out before diagnosing AHT. • The Tadpole Sign appears to be the most characteristic shape of BVT. • BVT can be depicted using CT, MRI and MR venography. • The Tadpole Sign suggests searching for other signs of AHT.

Role of neuroimaging in management of traumatic brain injury

Traumatic brain injury is a significant cause of morbidity and mortality in the UK with substantial associated economic costs to the healthcare system. This article explores the role of neuroimaging in both acute and long-term management of traumatic brain injury patients. We discuss the indications for urgent cross-section imaging as well as radiological features of both primary insults and secondary injuries. The role of neuroimaging in guiding surgical therapy and monitoring post-operative traumatic brain injury patients has also been described. Following initial injury, traumatic brain injury patients can suffer from a wide variety of physical, social and psychological difficulties. New techniques such as diffusion tensor imaging in combination with conventional magnetic resonance imaging sequences may provide useful information in predicting long-term prognosis and guiding rehabilitation.

Intracranial haemorrhage: an incidental finding at magnetic resonance imaging in a cohort of late preterm and term infants

BACKGROUND

Intracranial haemorrhage (ICH) in term newborns has been increasingly recognised but the occurrence in late preterm infants and the clinical presentation are still unclear.

OBJECTIVE

To investigate the appearance of intracranial haemorrhage at MRI in a cohort of infants born at 34 weeks' gestation or more and to correlate MRI findings with neonatal symptoms.

MATERIALS AND METHODS

We retrospectively reviewed neonatal brain MRI scans performed during a 3-year period. We included neonates ≥34 weeks' gestation with intracranial haemorrhage and compared findings with those in babies without intracranial haemorrhage. Babies were classified into three groups according to haemorrhage location: (1) infratentorial, (2) infra- and supratentorial, (3) infra- and supratentorial + parenchymal involvement.

RESULTS

Intracranial haemorrhage was observed in 36/240 babies (15%). All of these 36 had subdural haemorrhage. Sixteen babies were included in group 1; 16 in group 2; 4 in group 3. All infants in groups 1 and 2 were asymptomatic except one who was affected by intraventricular haemorrhage grade 3. Among the infants in group 3, who had intracranial haemorrhage with parenchymal involvement, three of the four (75%) presented with acute neurological symptoms. Uncomplicated spontaneous vaginal delivery was reported in 20/36 neonates (56%), vacuum extraction in 4 (11%) and caesarean section in 12 (33%). Babies with intracranial haemorrhage had significantly higher gestational age (38 ± 2 weeks vs. 37 ± 2 weeks) and birth weight (3,097 ± 485 g vs. 2,803 ± 741 g) compared to babies without intracranial haemorrhage and were more likely to be delivered vaginally than by caesarian section.

CONCLUSION

Mild intracranial haemorrhage (groups 1 and 2) is relatively common in late preterm and term infants, although it mostly represents an incidental finding in clinically asymptomatic babies; early neurological symptoms appear to be related to parenchymal involvement.

Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study

BACKGROUND

Few studies have focused on cerebral complications among newborn infants delivered by vacuum extraction (VE). The aim of this study was to determine the risk for intracranial haemorrhage and/or cerebral dysfunction in newborn infants delivered by VE and to compare this risk with that after cesarean section in labour (CS) and spontaneous vaginal delivery, respectively.

METHODS

Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010 including all singleton newborn infants delivered at term after onset of labour by VE (n = 87,150), CS (75,216) or spontaneous vaginal delivery (n = 851,347), we compared the odds for neonatal intracranial haemorrhage, traumatic or non-traumatic, convulsions or encephalopathy. Logistic regressions were used to calculate adjusted (for major risk factors and indication) odds ratios (AOR), using spontaneous vaginal delivery as reference group.

RESULTS

The rates of traumatic and non-traumatic intracranial hemorrhages were 0.8/10,000 and 3.8/1,000. VE deliveries provided 58% and 31.5% of the traumatic and non-traumatic cases, giving a ten-fold risk [AOR 10.05 (4.67-21.65)] and double risk [AOR 2.23 (1.57-3.16)], respectively. High birth weight and short mother were associated with the highest risks. Infants delivered by CS had no increased risk for intracranial hemorrhages. The risks for convulsions or encephalopathy were similar among infants delivered by VE and CS, exceeding the OR after non-assisted spontaneous vaginal delivery by two-to-three times.

CONCLUSION

Vacuum assisted delivery is associated with increased risk for neonatal intracranial hemorrhages. Although causality could not be established in this observational study, it is important to be aware of the increased risk of intracranial hemorrhages in VE deliveries, particularly in short women and large infants. The results warrant further studies in decision making and conduct of assisted vaginal delivery.