Neuroimaging of Nonaccidental Neuroimaging of Nonaccidental Head Trauma: Pitfalls, and Head Trauma: Pitfalls, and

ControversiesControversies11Ruby E Obaldo, MD, Ruby E Obaldo, MD, 22Irene Walsh, MD, Irene Walsh, MD,

and and 22Lisa H Lowe, MDLisa H Lowe, MD11Departments of Radiology, University of Kansas & Departments of Radiology, University of Kansas &

22ChildrenChildren’’s Mercy Hospital and Clinics and the s Mercy Hospital and Clinics and the University of MissouriUniversity of Missouri--Kansas CityKansas City

Learning objectives:Learning objectives:After viewing this exhibit, the reader After viewing this exhibit, the reader

should:should:Be familiar with various mimickers, Be familiar with various mimickers, pitfalls and controversies that occur in pitfalls and controversies that occur in neuroimaging of nonaccidental head neuroimaging of nonaccidental head trauma.trauma.Have an increased level of comfort Have an increased level of comfort distinguishing between nonaccidental distinguishing between nonaccidental head trauma and accidental injuries.head trauma and accidental injuries.

Introduction: Introduction: Author commentsAuthor commentsWhen reporting neuroimaging findings in When reporting neuroimaging findings in children who are potential victims of children who are potential victims of inflicted injury, radiologists must be inflicted injury, radiologists must be careful to render a balanced, objective careful to render a balanced, objective opinion regarding the imaging findings.opinion regarding the imaging findings.

While radiologists While radiologists must not overstate the must not overstate the importance of specific findingsimportance of specific findings, he or she , he or she must also must also make clear our concerns for make clear our concerns for possible inflicted injurypossible inflicted injury in the imaging in the imaging report to assist with potential report to assist with potential investigations.investigations.

Introduction: Introduction: CommentsComments

Imaging findings of nonaccidental head Imaging findings of nonaccidental head trauma (NHT), trauma (NHT), should always be interpreted should always be interpreted in the context of the clinical history and in the context of the clinical history and physical exam.physical exam.

The absence of clinical signs and symptoms The absence of clinical signs and symptoms does not exclude intracranial injury.does not exclude intracranial injury.– This is especially true in infants, so one

must have a high index of suspicion. – Screening head CT should be performed in

all infants with suspected inflicted injury.

Nonaccidental head trauma: Nonaccidental head trauma: FactsFacts

NHT is the leading cause of child abuse NHT is the leading cause of child abuse fatality and long term major morbidity.fatality and long term major morbidity.NHT is NHT is more common in infants and more common in infants and younger children. Thus, age is a helpful younger children. Thus, age is a helpful clue to the diagnosis.clue to the diagnosis.–– Average age NHT is 0.7 yearsAverage age NHT is 0.7 years–– Compared to Compared to 2.5 years for accidental 2.5 years for accidental

head traumahead traumaBoys (56%): girls (44%)Boys (56%): girls (44%)

Nonaccidental head trauma: Nonaccidental head trauma: FactsFacts

Risk factors for nonaccidental traumaRisk factors for nonaccidental trauma::Infant living in a household with an Infant living in a household with an unrelated adult male has a unrelated adult male has a 50X 50X increase increase rrisk of death due to head isk of death due to head injuryinjuryParent age <21 yearsParent age <21 yearsHistory of prenatal substance useHistory of prenatal substance useParents education Parents education ≤≤ 12 years12 years

Outline: Outline: Mimickers, pitfalls, Mimickers, pitfalls, questions and controversiesquestions and controversiesTopics to be discussedTopics to be discussed::

Skull fracturesSkull fractures –– dating, features that dating, features that suggest abuse, and the significance of suggest abuse, and the significance of scalp swellingscalp swellingHyperdense falx cerebri and tentorium Hyperdense falx cerebri and tentorium cerebellicerebelli ––normal variants vs. layering of normal variants vs. layering of subdural blood and cerebral edemasubdural blood and cerebral edemaBirth traumaBirth trauma –– distinguishing from child distinguishing from child abuseabuseHyperacute subdural hematoma (SDH)Hyperacute subdural hematoma (SDH) ––distinguishing from acute on chronic SDHsdistinguishing from acute on chronic SDHs

Outline: Outline: Mimickers, pitfalls, Mimickers, pitfalls, questions and controversiesquestions and controversiesTopics to be discussed continuedTopics to be discussed continued::

Benign enlarged subarachnoid spaces Benign enlarged subarachnoid spaces presenting with SDHspresenting with SDHs ––mimicker of NHTmimicker of NHTGlutaric aciduria type 1Glutaric aciduria type 1 –– mimicker of NHTmimicker of NHTHemophagocytic lymphocystosisHemophagocytic lymphocystosis--mimicker of NHTmimicker of NHTRetinal hemorrhagesRetinal hemorrhages –– features suggestive features suggestive of NHT and significance of NHT and significance Subdural hematomasSubdural hematomas –– significance and significance and features that suggest NHTfeatures that suggest NHT

Pitfall: Pitfall: Dating skull Dating skull fracturesfractures

Skull fractures are Skull fractures are common in abuse, common in abuse, but are nonbut are non--specificspecificSome patterns are Some patterns are suggestive, but not suggestive, but not diagnostic of abuse, diagnostic of abuse, including:including:–– Multiple, bilateral Multiple, bilateral

fractures that extend fractures that extend across suture lines across suture lines with suture diastasiswith suture diastasis

Skull fractures Skull fractures CANNOT be datedCANNOT be dated

Diastatic left parietal fractureDiastatic left parietal fracture in in a 6a 6--momo--old boy due to NAT 2 old boy due to NAT 2 weeks ago. The fracture (arrow) weeks ago. The fracture (arrow) appearance is nonappearance is non--specific.specific.

Pitfall: Pitfall: Skull fractures Skull fractures and scalp swellingand scalp swelling

NHT is often present NHT is often present WITHOUT scalp WITHOUT scalp swelling or hematoma swelling or hematoma Small or symmetric, Small or symmetric, hematomas are easily hematomas are easily missed on physical missed on physical examexamSoft tissue hematoma Soft tissue hematoma suggests, but is not suggests, but is not diagnostic of, acute diagnostic of, acute injuryinjury

Scalp hematoma in a 2-year-old female victim of NAT. CT shows an underlying tiny epidural hematoma (arrowhead). Adjacent skull fracture (not shown) was present.

Pitfall: Pitfall: Normal prominent tentorium Normal prominent tentorium and falx vs. SDH and cerebral edemaand falx vs. SDH and cerebral edema

The normal tentorium and falx appear The normal tentorium and falx appear hyerdense next to the relatively hyerdense next to the relatively hypoattenuated cerebral hemispheres, hypoattenuated cerebral hemispheres, which can mimic subdural hematomas or a which can mimic subdural hematomas or a ““cerebellar reversal signcerebellar reversal sign”” of cerebral edema.of cerebral edema.Helpful imaging featuresHelpful imaging features::–– Prominent falx cerebri and tentorium cerebelli Prominent falx cerebri and tentorium cerebelli

are typically seen in infantsare typically seen in infants, not older , not older children (SDHs can occur at any age).children (SDHs can occur at any age).

–– Prominent falx and tentorium are symmetricProminent falx and tentorium are symmetricbilaterallybilaterally, whereas SDHs are typically , whereas SDHs are typically asymmetric.asymmetric.

Pitfall: Pitfall: Normal prominent tentorium Normal prominent tentorium cerebelli vs. subdural bloodcerebelli vs. subdural blood

Normal prominent tentorium in two infants (normal variant). CT images show slight bilateral, symmetric hyperattenuation along the tentorium cerebelli.

NewbornNewborn 99--momo--oldold

Pitfall: Pitfall: Normal prominent Normal prominent tentorium vs. cerebral edematentorium vs. cerebral edema

Cerebral edema in a 7-month-old shaken female. CT image shows diffuse cerebral edema with relative sparing of cerebellum, the cerebellar reversal sign (arrow).

Severe cerebral edema in a 3-month-old male with severe hypoxic ischemic injury. Note edema of the cerebrum and cerebellum (C).

CC CC

Pitfall: Pitfall: NNoorrmmaall prominent falx prominent falx cerebri vs. interhemispheric SDHcerebri vs. interhemispheric SDH

Prominent falx cerebri and straight sinus (normal variants)in a 9-month-old infant. Note hyperdense symmetry (arrow).

Interhemispheric SDH in a 1-year-old male. Note the asymmetric thickening along the right side of the posterior falx (arrow).

Pitfall: Pitfall: Birth trauma vs NHTBirth trauma vs NHTBirth related Birth related skull skull fractures resolve by fractures resolve by 6 months of age.6 months of age.Birth Birth related SDHs related SDHs resolve by age 6 resolve by age 6 weeks.weeks.–– Birth related SDHs Birth related SDHs

are a common are a common (Forceps > vaginal > (Forceps > vaginal > CC--section delivery). section delivery).

–– They are rarely They are rarely symptomatic. symptomatic.

–– They rarely have They rarely have significant significant sequelaesequelae..

Small SDHs layering on the tentorium & falx in a 2-day-old male with seizures after difficult delivery (arrows).

Pitfall: Pitfall: Birth trauma vs NHTBirth trauma vs NHT

SDH in a 2-week-old male due to birth trauma. CT shows hyperdense blood (A) on the tentorium and (B) asymmetric thickening of the falx.

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Patient age may be the most useful feature to suggest a cause Patient age may be the most useful feature to suggest a cause of SDHs in infants under 6 weeks of ageof SDHs in infants under 6 weeks of age because the imaging because the imaging appearance of birth related skull fractures and SDHs are nonappearance of birth related skull fractures and SDHs are non--specific.specific.

Pitfall: Pitfall: Distinguishing hyperacute Distinguishing hyperacute SDHs from acute on chronic SDHsSDHs from acute on chronic SDHs

Hyperacute SDHHyperacute SDHHyperacute clinical Hyperacute clinical presentationpresentationMixed density within a Mixed density within a single collectionsingle collectionMass effectMass effectCerebral edemaCerebral edemaShort term follow up Short term follow up (within hours) shows (within hours) shows typical homogeneous typical homogeneous appearance of acute SDHappearance of acute SDH

Acute on chronic SDHAcute on chronic SDHLess acute Less acute presentationpresentationLayers of mixed Layers of mixed density separated by density separated by subdural membranessubdural membranesFrequent associated Frequent associated brain atrophy due to brain atrophy due to prior prior ““traumatic brain traumatic brain eventevent””

Pitfall: Pitfall: Distinguishing hDistinguishing hyperacute SDHs yperacute SDHs from acute on chronic SDHsfrom acute on chronic SDHs

Note: Note: typical findings of mixed typical findings of mixed attenuation within a single collection, attenuation within a single collection, mass effect and cerebral edema. mass effect and cerebral edema.

Left hyperacute SDHdue to NHT in a 14-month-old male. CT images show mixed density of incompletely clotted blood (arrow) and left cerebral edema with midline shift.

Pitfall: Pitfall: Distinguishing hyperacute Distinguishing hyperacute SDHs from acute on chronic SDHsSDHs from acute on chronic SDHs

Follow up CT 6 hours later shows the SDH is now homogenous in appearance (typical of acute SDH), confirming the initial diagnosis of hyperacute SDH.Hyperacute SDH was also confirmed during emergency surgery to relieve elevated intracranial pressure. Short term follow up of a hyperacute

SDH in a 2-year-old male victim of NHT. CT shows a homogeneously hyperdense (arrow) SDH, rightward midline shift & left cerebral edema.

Pitfall: Pitfall: AAcute on chronic or multicute on chronic or multi--age subdural hematomasage subdural hematomas

Subdural hematomas of Subdural hematomas of varied age can result from varied age can result from many conditions, and their many conditions, and their mere presence does not mere presence does not always indicate trauma.always indicate trauma.Acute on chronic SDHs, or Acute on chronic SDHs, or multiple SDHs of varied multiple SDHs of varied age, may result from a age, may result from a single traumatic event single traumatic event followed by repeated followed by repeated episodes of rebleeding into episodes of rebleeding into the original SDH, or result the original SDH, or result from multiple traumatic from multiple traumatic episodes.episodes.

Bilateral acute on chronic SDHs in a 15-month-old male due to NHT. Note diffuse enephalomalacia/atrophy indicating a remote event.

Pitfall: Pitfall: Distinguishing hyperacute SDHs Distinguishing hyperacute SDHs from acute on chronic SDHsfrom acute on chronic SDHs

Brain atrophy associated with SDHs of varied age suggests a prevBrain atrophy associated with SDHs of varied age suggests a previous ious event, and is suspicious for inflicted injuryevent, and is suspicious for inflicted injury. . As the brain shrinks away from the calvarium, the bridging veinsAs the brain shrinks away from the calvarium, the bridging veins are are stretched and often tear causing repeated episodes of SDH.stretched and often tear causing repeated episodes of SDH.

Chronic SDHs of varied age in a 4-month-old female who was shaken at 6 weeks of age. T1, T2, and FLAIR MR images show varied signal within layering bilateral SDHs that are separated by membranes. Associated diffuse brain atrophy suggests multiple episodes of rebleeding after the initial acute event.

IRIRT2T2T1T1

Pitfall: Pitfall: Expanded sExpanded subarachnoid ubarachnoid vs. subdural spaces on sonographyvs. subdural spaces on sonography

Sonography can be Sonography can be performed in infants performed in infants with open fontanels. with open fontanels. Sonography is most Sonography is most helpful to:helpful to:–– Screen developmentally Screen developmentally

normal children with normal children with macrocephaly. macrocephaly.

–– Distinguishing normal Distinguishing normal enlarged subarachnoid enlarged subarachnoid spaces from subdural spaces from subdural hematoma.hematoma.

Normal subarachnoid spaces in a 6-month-old infant. Doppler US shows normal crossing vessels (arrowheads) in the bilaterally symmetric subarachnoid spaces (arrowheads). Note the normal sagittal sinus (arrow).

Pitfall: Pitfall: Expanded sExpanded subarachnoid ubarachnoid vs. subdural spaces on sonographyvs. subdural spaces on sonography

Subarachnoid spaceSubarachnoid spaceContains numerous Contains numerous vessels on Dopplervessels on DopplerSymmetric fluid on Symmetric fluid on either side of the either side of the falxfalxCauses no mass Causes no mass effect on the brain effect on the brain or flattening of the or flattening of the sulcisulci

Subdural spaceSubdural spaceContains rare Contains rare crossing vesselscrossing vesselsAsymmetric fluid on Asymmetric fluid on either side of the either side of the falxfalxCauses mass effect Causes mass effect and flattening of the and flattening of the sulcisulciMembranes often Membranes often visiblevisible

Controversy: Controversy: Benign enlarged Benign enlarged subarachnoid spaces (BESS) & SDHssubarachnoid spaces (BESS) & SDHs

BESS is a BESS is a selfself--limiting limiting condition that presents condition that presents with with macrocephalymacrocephaly between 3 months and 3 between 3 months and 3 years of age years of age (mean: 6(mean: 6--18mo).18mo).It is also known as It is also known as external hydrocephalus external hydrocephalus and benign subdural effusions of infancy.and benign subdural effusions of infancy.The cause of BESS is hypothesized to be The cause of BESS is hypothesized to be transient communicating hydrocephalus due transient communicating hydrocephalus due to immaturity of the arachnoid villi.to immaturity of the arachnoid villi.

ControversyControversy: Can this condition : Can this condition predispose patients to develop SDHs and/or predispose patients to develop SDHs and/or retinal hemorrhages with little or no trauma?retinal hemorrhages with little or no trauma?

Controversy: Controversy: Benign enlarged Benign enlarged subarachnoid spaces (BESS) & SDHssubarachnoid spaces (BESS) & SDHs

BESS and bilateral SDHs in a 5-month-old developmentally normal male with macrocephaly. Gray scale US shows bilateral subdural membranes (arrows). Investigation for possible abuse was unrevealing.

Tiny left subdural hematoma(arrow) in 4-month-old male with multiple fractures. Note lack of crossing vessels and asymmetry. Investigation revealed NHT.

Controversy: Controversy: Retinal hemorrhages in Retinal hemorrhages in association with BESS and SDHsassociation with BESS and SDHs

SDHs associated with BESSSDHs associated with BESS have been reported on have been reported on numerous occasions. numerous occasions. –– Incidence of SDH in BESS is reported between Incidence of SDH in BESS is reported between

1% and 10%1% and 10%Retinal hemorrhages associated with SDH and BESSRetinal hemorrhages associated with SDH and BESSin a case report:in a case report:–– Report theorizes cause for retinal and SDHs was Report theorizes cause for retinal and SDHs was

altered mechanics of the subarachnoid space that altered mechanics of the subarachnoid space that may have transmitted pressure less effectively.may have transmitted pressure less effectively.

–– This report should be considered with caution as This report should be considered with caution as the described associated findings are well known, the described associated findings are well known, typical and extremely common in NHT.typical and extremely common in NHT.

Controversy: Controversy: Retinal hemorrhages Retinal hemorrhages (RHs), BESS and SDHs(RHs), BESS and SDHs

SDHs alone are weak evidence of NHT.

RH associated with SDH are strongly suggestive of abuse.

A child abuse investigation is prudent in the setting of SDHs with or without retinal hemorrhages.

SDH and BESS in a 6-month-old male with macrocephaly. Note lack of vessels in the subdural fluid (arrow) and flattening of the sulci. The child had no retinal hemorrhages or fractures.

Comment: Comment: Recommended screening for Recommended screening for inflicted injury in children with SDHs inflicted injury in children with SDHs and/or RHsand/or RHs

The suggested approach of one large The suggested approach of one large childrenchildren’’s hospitals hospital::Correlation with history and physical Correlation with history and physical exam to determine risk of abuse exam to determine risk of abuse Skeletal survey Skeletal survey Fundoscopic examFundoscopic examLab screening for bleeding diathesisLab screening for bleeding diathesisMetabolic screening if appropriateMetabolic screening if appropriate

PitfallPitfall: : Glutaric aciduria type 1Glutaric aciduria type 1

CauseCause: Autosomal recessive glutaryl: Autosomal recessive glutaryl--CoA CoA dehydrogenase deficiency that prevents dehydrogenase deficiency that prevents normal break down of amino acidsnormal break down of amino acidsBrain injuryBrain injury: Accumulation of intermediate : Accumulation of intermediate break down products (glutaric acid)break down products (glutaric acid)PresentationPresentation: Macrocephaly and seizures : Macrocephaly and seizures (20%), motor delay, mental retardation(20%), motor delay, mental retardationImagingImaging: Macrocephaly, frontotemporal : Macrocephaly, frontotemporal atrophy, subdural effusions, SDHs, white atrophy, subdural effusions, SDHs, white matter and basal ganglia T2 shorteningmatter and basal ganglia T2 shorteningRetinal hemorrhagesRetinal hemorrhages: 20% : 20% -- 30% 30% TreatmentTreatment: Dietary restriction: Dietary restrictionPrognosisPrognosis: Varies with age: Varies with age

Mimicker: Mimicker: Glutaric aciduria type1Glutaric aciduria type1Bitemporal atrophy and subdural fluid collections may Bitemporal atrophy and subdural fluid collections may predispose to development of SDHs mimicking NHT.predispose to development of SDHs mimicking NHT.

Glutaric aciduria type 1 in a 4-year-old male with macrocephaly and hypotonia. T2-weighted MR images reveal diffuse brain atrophy, most severe in the temporal lobes and posterior putamina. Diffuse patchy abnormal bright signal is also noted throughout the deep white matter.

Mimicker: Mimicker: Hemophagocytic Hemophagocytic lymphohistiocytosis vs. NHTlymphohistiocytosis vs. NHTRare nonmalignant disorder of immune Rare nonmalignant disorder of immune regulation.regulation.Presentation is nonPresentation is non--specific and may involve specific and may involve multiple organ systems including the brain.multiple organ systems including the brain.–– Hepatomegaly, fever and coagulopathy are Hepatomegaly, fever and coagulopathy are

common.common.–– RHs have been described, but are different than RHs have been described, but are different than

those of abuse.those of abuse.–– Bones are not involved.Bones are not involved.

Neuroimaging findings may overlap with NHT. Neuroimaging findings may overlap with NHT. However, the clinical presentations differ:However, the clinical presentations differ:–– Parenchymal & subdural blood, leptomeningeal Parenchymal & subdural blood, leptomeningeal

enhancement, focal necrosis and brain atrophy.enhancement, focal necrosis and brain atrophy.

MSK findings may suggest MSK findings may suggest abuse, including rib fractures abuse, including rib fractures and periosteal reaction.and periosteal reaction.Important to recognize early Important to recognize early because appropriate therapy because appropriate therapy can be life saving.can be life saving.PrognosisPrognosis: Fatal without : Fatal without treatment.treatment.RxRx: Immunosupressive : Immunosupressive chemotherapy and bone chemotherapy and bone marrow transplant.marrow transplant.

1111--dayday--old boy with HLH.old boy with HLH. CT CT scan shows left cerebral scan shows left cerebral edema and parenchymal edema and parenchymal blood (arrow).blood (arrow).

Image courtesy of Rooms, L. et al. Pediatrics 2003;111:e636-e640

Mimicker: Mimicker: Hemophagocytic lymphoHemophagocytic lympho--histiocytosis (HLH)histiocytosis (HLH)

Controversy:Controversy: Can hypoxia cause Can hypoxia cause SDHs and RHs without trauma?SDHs and RHs without trauma?

In the shaken or In the shaken or battered infants, battered infants, head head injuries are due to a injuries are due to a combination of direct combination of direct and indirect forces. and indirect forces. –– DirectDirect–– the head the head

strikes a stationary strikes a stationary objectobject

–– IndirectIndirect -- shaking shaking causes sudden causes sudden acceleration and acceleration and deceleration (shear deceleration (shear type injury).type injury).

Controversy:Controversy: Can hypoxia cause Can hypoxia cause SDHs and RHs without trauma?SDHs and RHs without trauma?

These forces also cause These forces also cause secondary injury, secondary injury, such as such as edema, herniation and edema, herniation and alternations leading to alternations leading to hypoxichypoxic--ischemic injury.ischemic injury.Some have theorized that Some have theorized that RHs and SDHs are the result RHs and SDHs are the result of hypoxic injury alone.of hypoxic injury alone.No research model has been No research model has been able to support this theory.able to support this theory.In deed, no cases of other In deed, no cases of other hypoxic disorders, such as hypoxic disorders, such as near drowning, have been near drowning, have been found to cause SDHs and found to cause SDHs and RHs.RHs.

Cerebral edema in a 7-month-old shaken baby. CT shows diffuse loss of the gray-white matter differentiation, loss of sulci and subarachnoid blood (arrow).

Controversy:Controversy: Can hypoxia cause SDHs Can hypoxia cause SDHs and RHs without trauma?and RHs without trauma?Since SDHs, RHs and hypoxic brain injury are well known Since SDHs, RHs and hypoxic brain injury are well known findings in NHT, potential inflicted injury must be investigatedfindings in NHT, potential inflicted injury must be investigated..

Cerebral edema and cerebral atrophy in a 9-month-old male victim of NHT. (A) CT at presentation shows diffuse loss of graywhite differentiation due to brain edema. (B) CT 7 days later reveals developing diffuse cerebral atrophy. Note parenchymal blood (arrow) and tiny SDH along falx.

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Cerebral edema Cerebral edema in a 3in a 3--momo--old old male with NHT. T2male with NHT. T2--weighted weighted MR image after craniectomy MR image after craniectomy shows massive left cerebral shows massive left cerebral swelling.swelling.

Retinal hemorrhages: Retinal hemorrhages: Features of Features of nonaccidental and accidental traumanonaccidental and accidental traumaNonaccidentalNonaccidental::

Multiple areas of Multiple areas of hemorrhagehemorrhageMultilayered Multilayered (involves the pre(involves the pre--and intraretinal and intraretinal layers)layers)Extend to the Extend to the periphery of the periphery of the retina, more retina, more anterioranterior

Accidental:Accidental:Usually Usually ipsilateral to ipsilateral to head traumahead traumaInvolve only the Involve only the retinal layerretinal layerFew in numberFew in numberPosterior Posterior locationlocation

Retinal hemorrhages: Retinal hemorrhages: Significance Significance and features of NHTand features of NHT

Retinal hemorrhages (RH) are common in abuse, but rare in Retinal hemorrhages (RH) are common in abuse, but rare in accidental head trauma.accidental head trauma.The retina should be examined in all children with The retina should be examined in all children with suspected abuse.suspected abuse.

Normal retinaNormal retina (A) compared to (B) numerous, multilayered (A) compared to (B) numerous, multilayered retinal retinal hemorrhageshemorrhages that increase in number that increase in number anteriorlyanteriorly..

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Pitfall: Pitfall: Many causes of retinal Many causes of retinal hemorrhagehemorrhageAll etiologies for RHs must be considered:All etiologies for RHs must be considered:

Hematologic abnormalitiesHematologic abnormalitiesInfectionInfectionTumorTumorNormal deliveryNormal deliveryVascular malformation or occlusionVascular malformation or occlusionRarely & controversially reported with Rarely & controversially reported with cardiopulmonary resuscitation cardiopulmonary resuscitation Complications with general anesthesiaComplications with general anesthesiaMetabolicMetabolicBujee jumpingBujee jumping

Retinal hemorrhages: Retinal hemorrhages: ImagingImaging

Imaging is not reliable for detection of RHs.Imaging is not reliable for detection of RHs.RHs are seen with imaging in far fewer RHs are seen with imaging in far fewer cases than are detected on fundoscopic cases than are detected on fundoscopic exam.exam.

Retinal hemorrhage in a 6-month-old shaken male. Axial CT image shows high density hemorrhage in the right globe (arrow). Occult RHs were found in the left globe on fundoscopic exam.

Retinal hemorrhages: Retinal hemorrhages: ImagingImaging

Retinal hemorrhage in an 10-month-old shaken female. (A) Axial T1W image and (B) Axial T2W MR images show abnormal bright signal in the left globe with a low signal margin on T2 image consistent with blood (arrows). Multiple bilateral multilayer RHs were found on fundoscopic exam.

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SDHs: SDHs: Significance and Significance and features of NHTfeatures of NHTAccidental SDHAccidental SDH::–– Usually unilateral and Usually unilateral and

located immediately inferior located immediately inferior to any skull fractures. to any skull fractures.

Inflicted SDHInflicted SDH::–– Commonly Commonly

interhemisphericinterhemispheric–– Bilateral Bilateral –– May occur remote May occur remote

to the site of the to the site of the fracture due to fracture due to inertial forces.inertial forces.

Subdural hematomain a 5-month-old male victim of NAT. CT images show acute (A) interhemispheric SDH (arrow) with (B) extension over the convexity of the brain (arrow).

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SDHs: SDHs: Significance and features of Significance and features of NHTNHT

Subdural Subdural hematomas are the hematomas are the most common most common intracranial intracranial manifestation of manifestation of child abuse.child abuse.

More common with More common with inflicted head inflicted head injury than injury than accidental trauma.accidental trauma.

Bilateral acute on chronic SDHs in an 8-month-old male. Note acute right (arrow) deoxyhemoglobin within the chronic subdural hygromas (arrowheads).

Conclusions: Conclusions:

By interpreting the neuroimaging By interpreting the neuroimaging findings of NHT in an objective findings of NHT in an objective manner and correlating injuries with manner and correlating injuries with the clinical context, the radiologist is the clinical context, the radiologist is able to provide important information able to provide important information that can be used in investigations of that can be used in investigations of potential inflicted injury.potential inflicted injury.

Conclusions:Conclusions:

Awareness of potential pitfalls, Awareness of potential pitfalls, normal variants, mimickers and normal variants, mimickers and controversies in the controversies in the neuroimaging of NHT will neuroimaging of NHT will increase comfort distinguishing increase comfort distinguishing nonaccidental from accidental nonaccidental from accidental head trauma.head trauma.

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