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Child Abuse, Brain


KEY FACTS

Terminology

  • Nonaccidental trauma, abusive head trauma (AHT)

  • Traumatic injury inflicted on infants & children by adults

Imaging

  • Direct impact injury: Direct blow to cranium or impact of skull on object

    • Calvarial (often complex) & skull base fractures

    • Focal brain injury deep to impact

  • Shaking injury: Result of violent “to & fro” motion of head

    • Subdural hematomas (SDH) in 90-98%

    • Generalized parenchymal injuries (cytotoxic edema, lacerations, axonal injury)

    • Bridging vein injury & thrombosis common

  • CT primary imaging tool in initial evaluation of AHT

    • Multiplanar reconstructions improve detection of

      • –

        Small intracranial hemorrhages

      • –

        Fractures (with bone algorithm & 3D reformats)

  • MR best for determining full extent of injury

    • DWI paramount for parenchymal injury

    • PD & SWI/T2* GRE for hemorrhage

    • T1 C+ for chronic SDH membranes

Top Differential Diagnoses

  • Accidental trauma

  • Benign macrocrania of infancy

  • Mitochondrial encephalopathies

  • Bleeding disorders

Clinical Issues

  • Presentation: Poor feeding, vomiting, irritability, seizures, lethargy, coma, apnea, retinal hemorrhages (∼ 75%)

    • Discordance between stated history & degree of injury: “Killer couch” (injuries blamed on infant rolling off couch)

  • #1 cause of brain injury death in children < 2 years of age

    • 17-25:100,000 annual incidence

    • Risk factors: Developmentally delayed, colicky, premature or low birth weight infants at higher risk

Posterior oblique view of a 3D NECT of the head in a 9 week old who “fell off the couch” shows multiple complex skull fractures
, including a displaced right parietal fracture
. The normal sagittal
& lambdoid
sutures are noted.

Axial NECT in the same 9 week old shows a right subdural hematoma (SDH)
& parenchymal laceration
with significant leftward midline shift
& sulcal effacement
.

Axial NECT in a 4-month-old boy with seizure activity shows multiple bilateral foci of low attenuation with loss of cortical differentiation
as well as a left frontal SDH
. There was no fracture, making these findings highly concerning for the shaking type of abusive head trauma (AHT).

Axial DWI MR in a 2-month-old boy with AHT shows areas of diffusion restriction
in the right frontal lobe & bilateral parietal lobes, consistent with parenchymal injury. MR is the most sensitive examination for brain parenchymal injury.

TERMINOLOGY

Abbreviations

  • Nonaccidental trauma (NAT), abusive head trauma (AHT), shaken-baby syndrome (SBS)

Definitions

  • Traumatic injury inflicted on infants & children by adults

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