Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse

Abstract

Background and purpose: Patients who have benign enlargement of the subarachnoid spaces (BESS) have long been suspected of having an increased propensity for subdural hematomas either spontaneously or as a result of accidental injury. Subdural hematomas in infants are often equated with nonaccidental trauma (NAT). A better understanding of the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental trauma may help distinguish this group of patients from those who suffer subdural hematomas as a result of NAT. The purpose of this study is to describe the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental injury in infants with BESS.

Methods: We conducted a retrospective review of all patients with BESS complicated by subdural hematomas evaluated at a single institution from 1998 to 2004. Data concerning the patient's clinical presentation, physical findings, imaging, and management are described.

Results: During the study period, 7 patients with BESS complicated by subdural hematoma were identified. Their mean age at identification of the subdural hematoma was 7.4 months of age. In 5 cases, there was no recognized trauma before identification of the subdural hematoma. In 3 cases, baseline CT or MR imaging was available, showing prominent subarachnoid spaces without any evidence of subdural hemorrhage.

Conclusion: Although suspicious for NAT, subdural hematomas can occur in children either spontaneously or as a result of accidental trauma. Caution must be exercised when investigating for NAT based on the sole presence of subdural hematomas, especially in children who are otherwise well and who have BESS.

Fig 1.

Axial fluid-attenuated inversion recovery MR image showing prominent CSF equivalent subarachnoid spaces in both frontal regions. No subdural hemorrhage is noted.

Fig 2.

Axial fluid-attenuated inversion recovery MR of same patient as in Fig 1 done 19 days later (patient remained hospitalized) now showing an isointense area in the left subdural space, consistent with a hematoma. The subarachnoid CSF space is seen clearly separate from the overlying subdural space containing the hematoma.

Fig 3.

Axial CT scan showing prominent subarachnoid spaces in both frontal regions.

Fig 4.

Axial fluid-attenuated inversion recovery MR sequence showing thin bilateral subdural hematomas that are seen separate from the underlying subarachnoid space.

Fig 5.

Axial T2-weighted MR image also showing the thin bilateral subdural hematomas.