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NEURORADIOLOGY
Summary
A shaking event is a common mechanism in abusive head trauma (AHT).
AHT is associated with greater morbidity and mortality than accidental (usually
outcome.
Published standards for the radiological investigation of AHT are available and
should be followed.
doi: 10.1259/img.20110067
2014 The British Institute of
Radiology
Cite this article as: Stoodley N, Williams M. The importance of neuroimaging in abusive head trauma. Imaging 2014;
23:20110067.
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Why bother?
A number of studies suggest that the overall incidence
of subdural haemorrhages occurring as a result of abusive
head trauma (AHT) seems fairly consistent at around
24 per 100 0001,2 (a similar incidence to that of all types of
cancer in the infant population). These studies obviously
only relate to infants and children who have presented to
a hospital and where the treating clinicians have requested
neuroimaging studies, which have subsequently shown
appearances consistent with AHT. It is probable that the
overall population incidence of subdural bleeding secondary to a shaking event is greater, as a proportion of
infants who sustain such an injury are likely to develop
transient and non-specific symptoms which resolve spontaneously and these infants are not presented to a hospital.
It is important to remember that the symptoms and signs
seen after an episode of AHT are not due to the subdural
haemorrhages but to the associated brain injury. The
commonest cause of subdural bleeding in infants is being
born, with MRI studies of normal, completely asymptomatic, term infants showing that the incidence of birthrelated subdural bleeding varies from 9% to 46%.3,4 The
lowest reported incidence of birth-related subdural bleeding follows elective Caesarean section and the highest
follows failed instrumental delivery (forceps and/or ventouse). Given the current UK birth rate, this equates to
a considerable number of babies who have birth-related
subdural bleeding that is clinically silent.
If birth-related subdural bleeding can be asymptomatic, it is likely that subdural bleeding from other causes
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assessment of the age of the blood (discussed further below). By themselves, these thin-film collections are not
space occupying and do not have any primary effect on
the underlying brain. The significance of these collections
of blood is therefore their very presence, not their (lack of)
effect on the underlying brain, and this means that, because they often appear so insignificant, their huge importance as markers of a mechanism of injury is too often
overlooked (Figure 2).
similar have very different outcomes according to the degree of associated brain injury (Figure 4).
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Fractures
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Figure 6. (a; iiii) CT scans showing uniformly low-attenuation subdural collections over both cerebral convexities due to acute
traumatic effusions. (b) MRI scan sequences from the same patient showing uniform signal collections on T1 (i) and T2 (ii), fluid
attenuation inversionrecovery (iii) and T2 gradient echo (iv) sequences.
Table 1. Factors that may help distinguish acute traumatic effusions and chronic subdural haematomas
Acute traumatic effusions
Common
Uniform attenuation/signal
No differentiating size: may be large or small
Often enlarge on sequential early scans
No membrane formation/loculation
May be asymmetrical or symmetrical, right vs left
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CT technique
Figure 7. (a) CT and (b) MRI axial T2 and (c) coronal fluid
attenuation inversionrecovery sequences showing loculated
chronic subdural haematomas with loculated areas showing
fluid with different signal intensities.
Imaging modalities
As in the imaging investigation of any other condition,
the various imaging modalities available to us have both
their strengths and limitations.
Plain radiographs
The skeletal survey remains an important investigation
in possible non-accidental injuries and skull radiographs
should form part of the skeletal survey even when a CT
scan of the head has been performed. Fractures that lie
along the plane of the scan sections can be missed on
standard CT (Figure 8).
Cerebral ultrasound
Although a very portable imaging modality, the severe
limitations associated with its use in this context make it
inherently unreliable. As discussed above, the imaging
marker of a shaking injury is of thin-film subdural haemorrhages over the posterior aspect of the cerebral
hemispheres and in the posterior fossa, as well as often
over the lateral aspects of the cerebral hemispheres; all
places are not well visualized on ultrasound (Figure 9).
Because of this, a normal ultrasound may well be falsely
reassuring and, if no other imaging investigations are
performed, this could mean that a child who has
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than in cases of hypoxicischaemic injury caused by nontraumatic events. It is also important to remember that,
especially in terms of the brain injury, the appearances at
the time of the scan are just that, a snapshot of what is
occurring at the time of the scan in an evolving pathological process. What we are looking at are static images
of a dynamic process and scans only a few hours apart
may look very different.
MRI technique
MRI has a very important role to play in the investigation of these cases both in the acute phase and in
the longer term. Given its multiplanar capability and the
ability to use different imaging sequences, it is well
recognized to be more sensitive than CT in the detection
of parenchymal brain injury of all types, at detecting
small volume subdural bleeds in sites not well seen on
CT and at detecting the small volume subarachnoid
haemorrhages that are very common in AHT (and are
the reason why, when lumbar punctures are performed
in these cases, it is very common to find uniformly
blood-stained CSF). Increasingly, MR investigations of
the spine are being performed at the same time as the
acute imaging of the head and spinal haemorrhage has
been reported in a significant proportion (approximately
5060%) of cases of AHT, most often in the lower thoracic and lumbar regions17,18 (Figure 10).
Given the accepted advantages of MRI over CT, including the fact that MRI does not involve the use of
ionizing radiation, why not just use MRI? There are
a number of reasons. Most units outside tertiary centres
do not have the capability to put sick infants with all the
requisite monitoring equipment into MRI scanners in any
event. Most radiologists in the district general hospital
setting (and many neuroradiologists without paediatric
expertise in teaching centres) would be uncomfortable
interpreting such scans, and it is easier to identify acute
blood on CT than on MRI: the early blood breakdown
products of oxy- and deoxyhaemoglobin can be very
subtle on MRI sequences, and it is not until methaemoglobin develops (which is bright on T1 weighted
scans) that blood becomes more obvious on MRI.
MRI also has a role in the longer term. As many of the
infants who sustain an episode of AHT are very young, it
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Imaging
Initial CT scan
A CT scan of the head should be performed as soon as
is reasonably possible following stabilization of the
childs clinical condition if this has been necessary. This
should include the whole head from foramen magnum to
vertex with a slice thickness no greater than 5 mm.
Is there evidence of acute (bright) subdural blood? If
so, where? Look carefully at the posterior falx and in the
posterior fossa. Does the falx appear brighter than it
should and/or irregular or asymmetrical? If so, there is
probably acute blood lying adjacent to it. Is there any
acute blood over the frontal regions?
Look at the CSF in the ventricles and then at the extraaxial spaces over the cerebral convexities. Is there evidence of extra-axial fluid that is darker than the brain but
brighter than the CSF? If so, this is likely to be fluid in the
subdural space (and hence abnormal), but it may not be
possible to tell whether this darker fluid is chronic subdural or acute effusion. If you cannot tell, say that you
cannot and do not assume that all dark subdural fluid is
chronic subdural haematoma (see above).
Look at the brain itself. Are there any focal abnormalities such as parenchymal haematomas or contusions
or areas of focal low attenuation that might be due to
diffuse axonal injury? Look at the overall attenuation of
the brain and the greywhite differentiation. Although
there is less difference between grey matter and unmyelinated white matter in the infant brain than in the
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Conclusions
Unfortunately, AHT involving a shaking mechanism is
a common clinical problem with a potentially devastating
outcome for all concerned. Despite our inability to perform scientific studies of such events on infants, the more
widespread availability and use of cross-sectional imaging techniques together with observational studies in this
and other types of head trauma has led to a greater understanding of the condition. The population of infants
that we see following AHT is no longer limited to those
who are admitted with obvious external signs of abuse or
in whom skeletal surveys show the presence of occult
bone injury.
Radiologists need to play a full part in the multidisciplinary team dealing with these cases and that means (a)
recognizing the relevant abnormalities as discussed above
and (b) reporting those abnormalities in terms of the possibility of them being due to AHT so that an appropriate
multidisciplinary team investigation can occur. Raising the
possibility of AHT in terms of the differential diagnosis of
the imaging features overall is not the same as getting
embroiled in the forensic process should the case go to
court, but it might make the difference between a child
being discharged back into an abusive environment and
Imaging 2014, 23, 20110067
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Further reading
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